A    TREATISE 


ON 


I 

THE   CONTINUED   FEVERS 


BY 

JAMES  C.  WILSON,  M.D., 

PHTSICIAS    TO    THE    PHILADELPHIA    HOSPITAL    AND    TO    THE    H03PITAL    OF    THE    JEFFBKSOS    MEDICAL    COL- 
LEGE, AND  LECTURER  ON  PHTSIOAL  DIAGNOSIS  AT  THE  JEFFERSON  MEDICAL  COLLEOB, 
FELLOW  OF  THE  COLLEGE  OF  PHYSICIANS  OF  PHILADELPHIA,  ETC. 


■WITH  AN  INTRODUCTION  BY 


J.  M.  DA  COSTA,  M.D., 


PBOFESSOB  OF  THE  PRACTICE  OF   MEDICINE    AND    CLINICAL    MEDICINE    AT   THE    JEFFERSON   MEDICAL    COL- 
LEGE,   PHYSICIAN   TO     THE    PENNSYLVANIA    HOSPITAL,    FELLOW    OF     THE    OOLLBOB 
OF    PHYSICIANS,    PHILADELPHIA,  ETC. 


NEW  YORK 
WILLIAM    WOOD    &    COMPANY 

27  Great  Jones  Street 
1881 


COPYBIOHT 

WILLLA.M    WOOD  &  COMPANY 

18S1 


Trow's 

Printing  and  Bookbinding  Company 

201-213  East  \ith  Street 

New  York 


f 


®o  the  ittemorg 


Dr.  WILLIAM   W.  GERHARD, 

WHO 

FIRST   IN  AMERICA  APPLIED   TO  THE   STUDY  OP  THE  FEVERS  THE  METHODS 
OP    MODERN    SCIENTIFIC   RESEARCH; 

AND  TO  WHOM  IS  DUE 

THE  CREDIT  OP    HAVING  FIRST   CLEARLY    ESTABLISHED   SEVERAL   OP    THE 
MOST  IMPORTANT   POINTS  OP  DISTINCTION 

BETWEEN 

TYPHUS  AND  TYPHOID  FEVERS. 


^C'^^oCO 


\ 


ilitoli' 


PREFACE. 


The  diseases  considered  in  tlie  following  pages  constitute  a  group 
with  most  of  which  the  general  practitioner  is  more  or  less  familiar ; 
it  has,  therefore,  been  my  aim  to  describe  them  at  greater  fulness 
than  is  usual  in  the  text-books,  yet  without  the  extreme  elabora- 
tion that  mars  the  usefulness  of  some  of  the  special  treatises.  Brief 
historical  sketches  have  been  introduced,  and  considerable  attention 
has  been  given  to  the  subject  of  the  special  causes  of  particular  dis- 
eases, as  well  as  to  their  clinical  phenomena  and  their  anatomical 
lesions.  Purely  theoretical  considerations  have  been,  as  a  rule,  omitted, 
and  all  controversial  matters  have  been  disregarded.  The  sections  upon 
treatment  are  designed  to  represent  recent  practical  knowledge,  rather 
than  to  do  justice  to  the  changing  opinions  of  which  that  knowledge  is 
the  outgrowth. 

With  reference  to  tlie  title  of  the  book,  it  is  to  be  admitted  that, 
despite  general  usage  and  the  highest  modern  authority,  the  classifica- 
tion of  the  infectious  diseases,  and  in  particular  of  those  commonly 
known  as  the  Fevers,  is  unscientific  and  provisional.  Diseases  being 
processes  and  not  entities,  are  properly  to  be  classified  upon  an  etio- 
logical basis.  Our  knowledge  of  the  exciting  causes  of  the  Fevers  does 
not  as  yet  admit  of  the  employment  of  such  a  principle  of  classifica- 
tion. Much,  however,  has  been  learned  within  recent  years,  and  new 
facts  are  from  day  to  day  being  brought  to  light :  the  expectation  that 
more  exact  and  definite  knowledge  of  the  special  causes  of  the  Fevers 


VI  PREFACE. 

V,  ill,  in  the  near  future,  lead  to  a  more  satisfactory  nosological  system, 
is  not  without  warrant. 

Meanwhile,  we  must  content  ourselves  with  groupings  based  upon  the 
broad  clinical  aspects  of  diseases.  From  this  point  of  view,  the  affec- 
tions treated  of  in  this  volume  constitute  a  group  sufficiently  well  de- 
fined. They  are  characterized  by  notable,  persistent  elevation  of  tem- 
perature, and  steady  continuance  to  a  definite  termination. 

The  group  might  have  been  made  larger  or  smaller,  but  the  time 
has  not  yet  come,  it  seems  to  me,  to  include  pneumonia,  diphtheria,  and 
acute  rheumatism,  among  the  Fevers,  and  I  can  find  no  reason,  seeing 
that  the  eruptions  of  dengue  are  variable  and  inconstant,  for  classing 
it  among  the  exanthematous  diseases. 

I  desire  to  express  my  thanks  to  my  friend.  Prof.  Wm.  H.  Greene, 
for  assistance  in  reading  and  correcting  the  proofs,  and  for  several  im- 
portant suggestions  as  to  the  arrangement  of  the  topics. 


JAMES   C.   WILSON. 


1437  Walnut  st.,  Philadelphia. 
28th  March,  1881. 


CONTENTS. 


Introdtjction  by  Professor  Da  Costa, 


I.— SIMPLE   CONTINUED   FEVER. 

Definition,           .............  1 

Synonyms,     .....          ...          ......  1 

Etiology, 2 

Clinical  History,     .............  3 

Analysis  of  the  Symptoms,        . 5 

Duration,        .          .............  7 

Dia^osis,            ..........•••  7 

Prognosis  and  Mortality,        .         .  . .8 

Treatment, 8 


II.  -INFLUENZA. 

Definition, 10 

Synonyms,           .............  10 

Historical  Sketch, .12 

Etiology, 21 

I. — Predisposing  Causes,          ..........  21 

II.— The  Exciting  Cause, 24 

Clinical  History, 26 

Analysis  of  the  Symptoms,         ..........  29 

The  Fever, 29 

The  Catarrh, 30 

Symptoms  Referable  to  the  Nervous  System, 32 

Complications  and  Sequels,         ..........  33 

Pathology, • 36 


Vlll  CONTENTS. 

PAOE 

Diagnosis, -37 

Prognosis  and  Mortality, 38 

Treatment,  .............  29 


III.— CEREBRO-SPINAL   FEVER. 

Definition, 40 

Synonyms,  .............  4G 

Historical  Sketch,  .............  47 

Etiology, 5G 

Clinical  History 64 

Analysis  of  the  Symptoms,         ..........  73 

Symptoms  Pertaining  to  the  Nervous  System,        .  .  ...  73 

Symptoms  Referable  to  the  Skin,        ........  77 

The  Phenomena  of  the  Fever,         .........  78 

Symptoms  Referable  to  the  Organs  of  Respiration,     .....  84 

Disturbances  of  the  Organs  of  the  Special  Senses,  .....  85 

Complications  and  Sequels,        ..........  87 

Pathology,  Morbid  Anatomy, 89 

Diagnosis,  ..............  94 

Prognosis  and  Mortality,       ...........  97 

Treatment, 98 


lY.— ENTERIC   OR   TYPHOID   FEVER. 

Definition, •         ...  107 

Synonyms,           .............  107 

Historical  Sketch, =         ...  108 

Etiology 116 

I. — Predisposing  Causes,         .         .         .         .         .         .         .         .        ,         .116 

II.— The  Exciting  Cause, 120 

Clinical  History, 147 

Analysis  of  the  Principal  Symptoms,          ........  153 

The  Phenomena  of  the  Fever,         .........  153 

Symptoms  Referable  to  the  Circulatory  System,          .....  161 

Symptoms  Referable  to  the  Nervous  System,          ......  163 

The  Skin, 167 

Symptoms  Referable  to  the  Digestive  Tract, 170 

Symptoms  Referable  to  the  Organs  of  Respiration, 176 

The  Urine, 177 

Complications  and  Sequels, .         .         .  178 

Varieties, "...  192 

Relapses 196 

Anatomical  Lesions, 202 


CONTENTS.  IX 

PAGE 

Diagnosis, 210 

Prognosis  and  Mortality, 213 

Treatment, 221 

I. — Prophylaxis,      ............  221 

II. — The  General  Management  of  the  Patient  and  Dietetics,      .         .         .  222 

III. — Special  Forms  of  Treatment, 227 

IV.— The  Expectant  Treatment, 234 

v. — The  Treatment  of  Special  Symptoms,  Complications,  and  Sequels,         .  235 

VI. — The  Management  of  the  Patient  during  Convalescence,      .         .         .  240 


•  V. -TYPHUS   FEVER. 

Definition, 241 

Synonyms, 241 

Historical  Sketch, 242 

Etiology, 251 

I. — Predisposing  Causes, 251 

II.— The  Exciting  Cause, 256 

Clinical  History, 260 

Analysis  of  the  Principal  Symptoms, 264 

Symptoms  Eef  arable  to  the  Nervous  System, 264 

The  Phenomena  of  the  Fever,     .........  269 

Symptoms  Manifested  by  the  Skin, 277 

Symptoms  Referable  to  the  Respiratory  System 281 

Symptoms  Referable  to  the  Digestive  System, 281 

Complications  and  Sequels,        ..........  284 

Varieties, 288 

Prognosis  and  Mortality, 290 

Anatomical  Lesions,       ............  293 

Diagnosis, 295 

Treatment, 297 


VI.— RELAPSING  FEVER. 

Definition, 303 

Synonyms,     ..............  302 

Historical  Sketch, .303 

Etiology, 309 

I. — Predisposing  Causes, 309 

II.— The  Exciting  Cause, 312 

Clinical  History, 320 

Analysis  of  the  Principal  Symptoms,   .........  324 

Symptoms  Referable  to  the  Nervous  System, 324 

The  Phenomena  of  the  Fever, 326 

Symptoms  due  to  Disturbance  of  the  Digestive  Organs,      ....  331 


X  CONTENTS. 

PAGE 

Complications  and  Sequels, 332 

Prognosis  and  Mortality, 335 

Anatomical  Lesions, 836 

Diagnosis, 337 

Treatment, 340 


VII.— DENGUE. 

Definition,  .        .        .        , 344 

Synonyms, 344 

Historical  Sketch, 345 

Etiology, 348 

I. — Predisposing  Causes, 348 

11. —The  Exciting  Cause, 349 

Clinical  History, 350 

Diagnosis, 356 

Treatment, 356 


THE  CONTIJ^UED  FEVERS. 


INTEODUCTIOK 


I  HAVE  been  asked  to  wi-ite  an  introduction  to  Dr.  Wilson's  work 
on  Fevers,  and  I  shall  choose  for  my  subject  that  most  important  one, 
the  management  of  Fever.  For  what  is  the  study  of  its  causation, 
what  the  care  in  its  discrimination,  what  the  close  pursuit  of  the  le- 
sions in  solids  and  in  blood,  unless  we  are  thus  to  be  led  to  a  more 
clearly  conceived,  more  thoughtful,  more  successful  management  of 
the  Fever?  As  the  scope  of  this  work  is  limited  to  the  Continued 
Fevers,  so  my  remarks  will  chiefly  refer  to  them.  But  there  is  little 
that  I  shall  say  that  in  the  main  would  not  be  applicable  to  the  other 
members  of  the  great  family  of  Fevers. 

We  naturally  have  to  consider,  first,  the  general  management  of  the 
fever,  as  it  is  influenced  by  the  arrangements  of  the  sick-room,  and  by 
tlie  attendance  to  the  wants  of  the  patient — those  things  which  imply 
his  nursing.  ]^ow,  we  all  agree  that  good  nursing  is  essential ;  but 
do  we  all  enforce  it,  and  continue  to  superintend  it  ?  The  physician 
who  lays  aside  his  watchfulness  on  these  points,  finds  at  any  moment 
that  he  is  combating  with  one  of  his  chief  weapons  broken  in  his 
hand.  Reports  from  the  nurse — written  when  practicable,  inspection 
of  the  arrangements  for  ventilation,  for  destroying  the  discharges,  for 
insuring  the  cleanliness  of  the  patient,  should  form  part  of  the  occupa- 
tion of  at  least  one  of  the  da.i]j  visits. 

So  much  has  been  said  of  late  years  of  the  functions  of  the  nurse, 
and  there  are  now  so  many  more  well-trained  nurses,  that  it  will  be 
quite  unnecessary  here  to  go  into  any  details  of  the  nursing  of  fever- 
patients.  But  the  last  word  on  this  subject  can  never  be  spoken.  It 
never  can  be  too  strongly  enforced  that  cleanliness,  cheerfulness,  and 
regularity,  are  the  three  great  qualities  needed  in  the  sick-room. 

The  cleanliness  consists  in  keeping  him  personally  clean — in  spong- 
ing him  with  cool  or  tepid  water,  or  with  vinegar,  or  bay-rum  and 


Xll  INTRODUCTION. 

Mater,  morning  and  evening,  only  parts  of  the  body  at  a  time,  if 
more  fatigue  liim  ;  in  seeing  to  it  that  his  linen  is  unsoiled  ;  and  that 
the  room  is  not  encumbered  with  anything  useless,  and  that  all  objects 
are  fi*ee  from  stain  and  in  good  order.  The  cheerfulness  sustains  his 
spirits,  and,  mitil  his  nervous  system  is  stricken  with  obtuseness,  is  a 
vast  comfort  and  aid  during  his  dreary,  restless  hours. 

The  regularity  is  indispensable  ;  everything  must  be  given  at  hours 
arranged  by  the  physician.  Well-meant  but  injudicious  kindness  may 
give  food  and  medicine  of tener,  or  fail  to  give  them,  fearing  to  disturb. 
J3ut  well-meant  though  injudicious  kindness  may  thus  hasten  or  cause 
death.  Except  nnder  the  most  potent  of  causes,  the  schedule  arranged 
by  the  physician  must  not  be  departed  from.  Of  course,  in  these 
directions  some  latitude  Avill  be  left  as  to  how  long  the  patient  may 
be  allowed  to  sleej),  or  under  what  circumstances  a  dose  may  be  re- 
peated or  be  omitted.  But  a  careful  physician  indicates  this  latitude 
with  his  directions. 

Besides  these  points  essential  to  good  nursing,  there  are  others — 
some  quite,  others  almost  equally  important.  Equally  important  cer- 
tainly is  ventilation,  admitting  light  and  air  both,  not  excluding  them  as 
if  they  were  poisonous.  To  admit  light  is  to  influence  the  nervous  sys- 
tem favorably,  to  keep  the  half-dreamy,  wandering  attention  aroused,  to 
procure  better  sleep  by  marking  tlie  alternations  between  day  and  night 
and  invoking  the  force  of  habit,  to  moderate  often  a  delirium.  To  ad- 
mit pure  air  is  to  give  the  respiratory  functions  their  full  play  and  to 
furnish  the  changed  blood  with  the  means  requisite  for  its  revival. 
Moreover,  it  cools  the  atmosphere,  which  indeed,  even  in  winter,  should 
be  kept  at  a  very  moderate  degree  of  heat ;  and  this,  to  the  patient 
consumed  witli  fever,  is  both  grateful  and  salutary.  We  see  what  a 
calamity  a  hot  atmosphere  is  if  we  are  obliged  to  treat  severe  cases  of 
typhoid  fever  in  our  cities  during  the  summer  months.  They  are 
likely  to  do  badly — the  heat  adds  to  their  gravity  and  prostrates  the 
nervous  system.  I  have  often  attempted  to  cool  the  atmosphere  by 
artificial  means,  and  have  used,  with  at  least  partial  success,  cloths 
wrung  out  in  ice-water,  and  hung  up  near  an  open  window ;  I  have  re- 
sorted to  blocks  of  ice  that  are  allowed  to  melt  in  the  room,  and  to- the 
hand-ball  atomizer  charged  with  ice-water  or  cologne  and  water,  so  as 
to  fill  the  room  with  the  spray.  But,  with  all,  the  torrid  weather  of  our 
heated  term  is  a  terrible  drawback  in  the  treatment  of  e:rave  fevers. 

Another  important  point  in  the  care  of  the  sick  person  is  that  he 
should  not  be  needlessly  disturbed.  And  here  it  is  where  the  well- 
trained  professional  nurse  is  such  an  advantage.  Fussiness  is  a  de- 
structive quality  ;  and  ignorance  is  always  fussy.     Nm-ses  who  know 


IlSrTRODUCTIOlSr.  xiu 

their  business  but  imperfectly  are  apt  to  be  always  in  motion,  always 
addressing  the  unfortunate  patient,  keeping  him  awake  when  he  wants 
to  sleep,  constantly  forcing  drinks  on  him,  never  resting  themselves  or 
letting  him  rest.  And  it  must  be  said  that  the  overanxious  eye  and 
hand  of  affection  are  sometimes  as  injurious  as  the  annoyance  of  the 
well-meaning,  meddlesome  nurse.  The  solitude  which  implies  seve- 
rance fi"om  loving  watchfulness  is  very  bad ;  but  it  may  be  better  than 
the  unrest  which  loving  watchfulness  misdirected  occasions. 

A  fever-patient  should  be  put  to  bed  early ;  it  saves  his  strength. 
We  see  what  comes  of  not  doing  it,  in  the  result  of  the  so-called  walk- 
ing cases,  especially  in  typhoid  fever  and  in  yellow  fever ;  they  are 
very  apt  to  do  badly.  But  how  long  should  the  patient  be  kept  in 
bed  ?  I  think  not  too  long.  To  put  him  to  bed  early  and  to  let  him 
up  early  is  my  rule.  If  the  thermometer  for  three  or  four  days  have 
marked  a  normal  evening  temperature,  I  allow  him  to  get  up,  at  first 
for  half  an  hour  or  less,  and  then  daily  more  and  more.  I  have  known 
this  plan  succeed  admirably  in  what  seemed  a  protracted  convalescence, 
and  put  a  stop  to  night-sweats  and  to  temperature-rises  to  100° ;  for 
I  think  we  may  keep  the  temperature  at  that,  or  let  it  go  back  to 
that,  by  allowing  the  patient  to  stay  too  long  in  bed. 

The  diet  varies,  of  course,  with  the  character  of  the  fever.  The 
t}^hoid  fever  patient,  with  his  ulcerating  intestine,  will  not  bear  the 
same  diet  as  the  typhus  fever  or  catarrhal  fever  patient.  Yet  in  the 
main  there  is  such  a  thing  as  a  fever-diet,  and  that  is,  a  restricted  diet 
of  bland,  easily  digested  substances.  The  coated  state  of  the  mucous 
membrane,  the  difficulty  of  digestion,  the  J5,ck  of  appetite,  make  the 
sick  man  turn  almost  with  disgust  from  other  food.  Hence,  broths, 
and  milk,  and  farinaceous  food  form  the  staple  of  the  diet,  whether  he 
have  an  intestinal  lesion  or  not ;  and  by  the  loathing  for  food  JS^ature 
restricts  the  diet,  whether  we  restrict  it  or  not.  Indeed,  since  the 
memorable  words  which  Graves  chose  for  his  epitaph — "  He  fed  fevers  " 
— it  cannot  be  said  that  the  English-speaking  races,  at  least,  attempt  to 
curtail  the  diet  much.  Our  error,  I  think,  is  now  in  the  other  direc- 
tion ;  in  the  earlier  stages  of  the  fever  we  do  not  curtail  it  enough.  As 
regards  the  character  of  food,  while  the  articles  mentioned  are  those 
generally  most  acceptable,  they  need  not,  except  in  the  case  of  typhoid 
fever,  be  as  rigidly  adhered  to  as  is  the  wont.  If  the  patient  crave 
other  food — crave  solid  food  not  actually  indigestible,  he  may  have  it. 
Later  in  the  febrile  malady  assuredly  the  tone  of  the  stomach  may  be 
better  sustained  by  some  solid  than  by  so  much  liquid  nourishment. 

From  the  cruel  practice  of  refusing  water  to  the  fever-stricken  pa- 
tient, there  has  been,  we  all  know,  a  strong  reaction.     And  it  is  one  of 


XIV  INTRODUCTION. 

the  doctrines  now  unreservedly  tauglit,  to  allow  tlie  patient  an  nnllmited 
supply  of  pure  water  or  of  other  bland  fluid.  That  in  the  main  this  is 
right,  there  can  be  no  question.  It  is  not  simply  a  gratification  to 
quench  the  burning  thirst,  but  it  means  to  get  rid  of  the  poison  and  of 
broken-down  tissues  by  keeping  skin  and  kidneys  active.  Yet,  is  it 
proper  that  the  supply  should  be  unlimited  ?  I  think  we  have  gone 
too  far  in  saying  that  it  shall  be.  Yery  large  supplies  of  water  mean 
that  the  vessels  of  the  stomach  are  constantly  full,  that  the  process  of 
taking  up  liquid  food  is  retarded — nay,  that  the  desire  for  the  really 
essential  nourishment  is  greatly  lessened  or  is  changed  to  repugnance. 

Closely  connected  with  the  subject  of  food  and  drink  is  that  of 
stimulants.  I  cannot  here  go  into  the  question  of  giving  alcohol  in 
fevers,  because  the  propriety  or  impropriety  has  to  be  judged  in  each 
fever,  and  general  statements  are  apt  to  be  misleading.  "VYe  cannot 
make  hard-and-fast  rides  that  will  apply  equally  in  t}^:)hoid  and  in  in- 
fluenza, in  cerebro-spinal  fever  and  in  relapsing  fever.  Still  there 
are,  besides  many  special  indications,  some  comprehensive  ones  which, 
though  in  different  degree,  turn  up  in  all  fevers,  and  are  to  be  met  in 
the  same  way.  Whenever  there  are  signs  of  failing  circulation,  when- 
ever the  action  of  the  heart  becomes  enfeebled,  stimulants  are  de- 
manded. And  we  have  no  better  guide  in  this  than  the  law  Stokes 
enunciated  long  since  in  typhus  fever,  and  which  more  recent  observa- 
tions have  applied  to  typhoid — the  state  of  the  first  sound  of  the  heart. 
This,  indeed,  can  be  made  use  of  with  advantage  in  all  fevers.  Let 
the  first  sound  become  short,  indistinct,  almost  suppressed,  and  we 
have  a  certain  indication  ft)r  alcohol ;  the  fainter  the  first  sound,  the 
more  urgent  is  the  stimulus  required.  jS^ow,  the  pulse  aids  also  in 
determining  the  question ;  yet  it  is  not  so  certain.  But  both  pulse  and 
heart-sounds  are  much  more  available  than  the  sphygmograph,  which, 
though  employed  by  some,  is  quite  unsuited  to  the  exigencies  of  pro- 
fessional life  in  framing  the  treatment  of  fever-cases. 

Tremor  and  delirium  are  other  signs  which  call  for  stimulants ; 
they  are  mostly  the  result  of  failing  nervous  power.  Yet,  certainly 
with  reference  to  delirium,  we  cannot  make  our  rule  too  absolute. 
Delirium  may  be  due,  not  to  defective  nerve-energ}^  and  poisoned  blood, 
but  to  intracranial  mischief,  though,  excepting  cerebro-spinal  fever, 
such  is  rarely  the  case. 

We  now  arrive  at  the  treatment  of  fever  by  strictly  medicinal 
means.  At  the  very  threshold  we  come  across  the  inquiry :  Are 
there  special  plans  of  treatment  for  these  fevers  of  the  Continued 
Type — plans  of  treatment  approaching  to  specifics,  leading  rapidly  to 
cure — having,  in  other  words,  the  power  or  something  like  the  ]>ower, 


INTEODUCTIOIT.  XV 

wliicli  the  preparations  of  bark  exert  over  the  fevers  of  the  Periodical 
Type  ?  Or  are  we  in  the  main  still  forced  to  treat  the  fevers  on  what 
is  called  the  rational  plan — to  treat,  therefore,  chiefly  the  symptoms 
until  the  poison  is  eliminated  or  its  results  disappear  ?  It  may  be  a 
humiliating  statement,  but  it  is  true  that  in  the  main  such  is  the  case. 
There  are  in  some  fevers  special  plans  of  treatment  which  aim  at 
modifying  the  poison  or  the  disease  itself,  which  are,  I  believe,  worthy 
of  confidence,  and  are  better  than  the  so-called  rational  treatment ; 
such  I  hold  to  be,  for  instance,  the  treatment  of  the  typh-fevers  by  the 
mineral  acids,  of  cerebro- spinal  fever  by  opium.  But  these  plans  of 
treatment  are  few,  and  are  not  pre-eminent  and  striking.  The  result,  on 
the  whole,  is  better  when  they  are  employed,  yet  they  are  not  curative 
in  the  highest  degree  ;  and  under  any  circumstances,  there  are  but  a 
scanty  number  which  have  stood  the  test  at  all.  Most  of  the  special 
plans  proposed  are  mixed  up  with  a  quantity  of  unmistakable  rubbish, 
and  have  been  cleared  away ;  the  accumulated  experience  of  many 
minds  acting  as  an  ultimate  court  of  appeal  has  given  judgment  in 
favor  of  very  few,  and  among  these  have  not  been  any  based  on 
remedies  of  extraordinary  kind  or  preconceived  action.  The  best 
high  road  to  success  is  still  the  high  road  of  the  commonplace. 

But  it  would  be  as  illogical  as  absurd  to  suppose  that  we  shall 
never  possess  the  coveted  means  really  to  cure  the  continued  fevers. 
Doubtless,  to  the  physician  of  the  time  of  Charles  Y.  the  radical  and 
specific  treatment  of  the  malarial  fevers  appeared  as  hopeless  and  re- 
mote as  the  radical  and  specific  treatment  of  the  continued  fevers  ap- 
pears to  the  scientific  inquirer  of  our  day. 

If,  then,  we  are  still  obliged  to  treat  the  fevers  of  continued  type 
rather  on  general  principles  than  by  remedies  that  are  specific,  we  have 
to  look  to  those  indications,  and  to  depend  largely  on  those  agents  which 
enable  us  to  control  the  fever-process.  Among  these  indications  there 
are  a  few  of  paramount  importance. 

One,  certainly,  is  to  watch  and  to  keep  up  the  secretions.  It  is  bet- 
ter for  every  fever  that  the  skin  should  be  moist,  than  that  it  should 
be  harsh  and  dry.  It  is  better  that  the  urine  should  be  abundant,  than 
that  it  should  be  scanty  and  thick  with  tissue-waste.  And  it  is  not 
enough  to  judge  by  the  rough  tests  with  which  the  older  physicians 
were  familiar— we  must  resort  to  the  more  accurate  chemical  means. 
Testing  the  urine  for  albumen  has  much  significance.  It  is  some  kind 
of  guide  to  the  depth  of  the  impression  the  fever-poison  has  made  on 
blood  and  nervous  system.  The  abnormal  ingredient  is  not  present  in 
light  cases ;  it  is  rarely  absent  in  grave  ones.  Watching  the  stools,  too, 
and  seeing  that  they  are  regular,  is  of  value.     Leaving  out  the  special 


XVI  INTRODUCTIOX. 

character  wliicli  comes  from  the  lesion  in  typhoid  fever,  in  all  fevers 
'  we  can  judge  by  them  whether  the  food  taken,  he  it  solid  or  milk,  is 
being  digested;   whether,  therefore,  it   had  better  be   continued   or 
changed. 

To  reduce  the  elevated  temperature  of  the  fever  is  to  all  a  most  im- 
portant, and  to  some  the  most  important  indication.     This  is  accom- 
plished by  sponging  the  skin  with  cool  water,  by  seeing  that  it  acts 
freely,  and  by  the  use  of  drugs  M'hich  lower  temperature.     But  the 
most  potent  agent  undoubtedly  is  the  cold  bath,  and  the  treatment  of 
fevers,  especially  of  typhoid  fever,  by  cold  baths,  is  one  which  is  now 
being  strongly  urged  on  professional  attention.     Some  employ  it  in 
all  cases,  others  only  in  those  in  which  the  temperature  exceeds  103°. 
To  carry  out  this  apyretic  treatment  effectually  requires,  however,  such 
constant  repetition  of  the  bath,  such  extreme  care  in  the  assistants, 
such  facilities  for  resorting  to  it  without  fatigue,  and  such  implicit  obe- 
dience on  the  part  of  the  patient,  or  rather  of  his  friends,  that  m  pri- 
vate practice,  at  least,  it  is  in  this  country  impracticable.     And  it  is  not 
settled  that  for  ordinary  cases  it  is  so  superior  to  other  plans  that  we 
are  bound  to  insist  upon  the  discomfort  and  annoyance  which  attend 
it.     Still,  for  cases  of  very  high  temperature,  cases  of  about  105°  or  up- 
wards, unless  extreme  exhaustion  or  some  other  contra-indicatiou  for- 
bids, it  is  right  to  resort  to  it.     High  temperature  then  becomes  in 
itself  dangerous  to  life,  and  we  try  to  subdue  the  bad  symptom  to  pre- 
serve life.     I  have  several  times  in  the  last  few  years  made  use  of  the 
cold-water  treatment  under  these  circumstances,  and  seen  it  act  well. 
I  have  also  known  the  cold-water  bath  to  overcome  that  bad  and  de- 
structive s}Tnptom  of  fever,  sleeplessness,  where  anodynes  had  failed. 
Other  means  to  reduce  the  temperature  are  quinine  and  the  salicylate 
of  sodium.     Quinine  in  large  doses  has,  on  the  whole,  proved  its  power 
to  do  so,  certainly  in  t}-phoid  and  typhus  fevers.     Yet  it  is  sometimes 
disappointing,  particularly  in  this,  that  the  effect  gained  is  not  at  all  per- 
manent.    Moreover,  we  must  be  careful  not  to  infer  that  sulphate  of 
quinia  is  to  be  employed  in  all  the  fevers  of  the  continued  type,  to 
bring  about  the  results  mentioned.     Clinical  experience  will  have  to  be 
recorded  for  its  use  in  each  fever.     Granting  that  it  always  has  the  same 
effect,  such  large  doses  cannot  be  given  M'itli  impmiity  in  various  and 
dissimilar  pathological  conditions ;  and  it  is  very  possible  that,  while 
they  reduce  the  temperature,  they  may  aggravate  the  disease  or  some 
of  the  lesions.    That  this  does  not  happen  in  tj^-phoid  and  typhus  fever, 
has,  I  think,  been  proved ;  for  the  other  members  of  the  group  the 
problem  has  not,  from  this  point  of  view,  been  worked  out.     Salicylate 
of  sodium  is  too  new  a  remedy  to  have  been  fairly  tested ;  that  it  re- 


INTRODUCTION.  XVll 

duces  temperature  we  know.  But  it  is  more  apt  to  disturb  digestion 
than  quiuia,  and  acting,  as  it  often  does,  as  a  depressant  to  the  heart, 
its  use  in  low  fevers  will  require  considerable  caution. 

To  control  and  influence  the  circulation  is  an  indication  second  to 
none  in  the  treatment  of  the  continued  fevers.  In  those,  far  rarer  in- 
stances, in  which  the  circulation  is  too  active  and  the  powers  of  the  heart 
increased — in  fevers,  therefore,  of  what  were  formerly  called  ardent  or 
inflammatory  type,  there  is  in  my  experience  no  remedy  equal  to  aco- 
nite in  quieting  heart  and  pulse.  Li  the  much  more  usual  indication  of 
defective  cardiac  action  which  sooner  or  later  is  apt  to  show  itself  in 
the  course  of  most  fevers,  alcohol  steadies  the  feeble  heart  more  cer- 
tainly than  anything  else.  Quinia  in  small  doses,  or  strychnia,  aids ; 
but  alcohol  exerts  by  far  the  most  influence.  Digitalis,  from  which  we 
might  expect  so  much,  has  disappointed  me ;  at  least  it  has  done  so  re- 
peatedly in  typhoid  fever. 

There  is  another  point  connected  with  the  management  of  fevers  as 
important  as  any  that  has  been  stated.  It  refers  not  to  the  sick-room, 
nor  to  the  sick  man,  but  to  the  doctor :  he  must  manage  himself.  jSToth- 
ing  is  worse  than  a  vacillating  physician,  whom  each  motion,  each  wish 
of  the  patient,  each  suggestion  of  the  nurse  or  of  the  family,  affects. 
Blown  hither  and  thither  by  every  breath,  incapable  of  taking  a  broad 
view  of  the  case,  his  treatment  soon  becomes  as  irresolute  as  himself, 
and  directions  and  bottles  accunmlate  with  bewildering  raj)idity.  The 
fewer  drugs  that  are  used,  the  better  ;  the  greater  the  decision  with  which 
the  drugs  are  used,  the  better.  To  do  this  effectually  the  physician  must 
understand  the  mode  of  onset  of  the  fever,  its  probable  length,  its 
natural  course,  the  succession  and  duration  of  each  symptom,  its  de- 
pendence or  non-dependence  upon  a  fixed  lesion,  the  kind  of  complica- 
tion likely  to  arise  and  the  time  at  which  it  is  apt  to  set  in ;  he  must,  in 
one  word,  be  pathologist  as  well  as  physician.  lie  then  knows  when  to 
act  and  when  not  to  act.  And  in  so  doing  we  have  learned  equally 
from  men  and  nature.  From  men  we  have  learned  what  agents  to 
employ  when  we  wish  to  make  strong  impressions  ;  from  nature  the 
uselessness  or  folly  of  such  attempts  when  the  fever  is  pursuing  an  even 
course. 

Yet,  to  treat  a  case  with  the  best  chance  of  success,  still  something 
else  is  required — the  practical  skill  which  takes  note  of  the  epidemic 
influence  prevailing ;  which  recognizes  that  all  cases  are  not  alike  because 
they  bear  the  same  name  ;  which  does  not  overlook  that  in  the  same  dis- 
ease apparently  the  brunt  may  fall  primarily  on  this  organ  or  on  that 
organ,  that  the  nervous  system  or  the  circulation  may  suffer  dispropor- 


XVUl  INTRODUCTION. 

tionately  and  exceptionally  from  the  onset,  or,  as  in  fevers  of  the  worst 
form,  be  overwhelmed  together ;  which  lays  stress  on  peculiarity  of 
causation,  of  temperament,  of  constitution ;  which  sees,  therefore,  not 
only  the  disease  in  the  sick  man,  but  the  sick  man  in  the  disease.  And 
another  quality  enters  into  the  achievement  of  greatest  success — the 
tenacity  which  never  abandons  a  case  while  there  is  life.  In  diseases 
that  are  self -limited,  to  continue  to  sustain  to  the  last  is  to  give  nature 
the  chance  of  exerting  a  power  of  recuperation  which  art  cannot 
gauge. 

J.  M.  DA  COSTA. 


I. 

SIMPLE  CONTmUED  FEYER. 

Definition. — A  continued  fever,  not  due  to  specific  cause,  usually  of 
short  duration,  lacking  the  distinguishing  characteristics  of  the  other 
fevers,  rarely  fatal  in  temperate  climates,  and  showing,  when  death 
occurs,  no  characteristic  lesion. 

Synonyms. — Febricula;  Ephemeral  fever;  Common  continued  fever;  Sun 
and  Heat  fever;  Ardent  continued  fever;  Febris  continua  simplex; 

Synocha. 

Much  confusion  has  arisen  in  consequence  of  the  use  of  the  term  sim- 
ple continued  fever,  by  different  authors,  to  designate  several  distinct 
affections.  It  has  been  a  category  for  many  cases  of  uncertain  character. 
It  has  been  made  to  include  cases  arising  during  epidemics  of  fever,  as 
for  example,  typhus  or  yellow  fever,  that  have  lacked  the  distinguishing 
features  of  the  prevalent  disease  on  the  one  hand  and  the  traits  of  the 
other  essential  fevers  on  the  other.  It  has  been  applied  where  enteric 
fever  and  remittent  were  endemic,  to  cases  of  fever  occurring  side  by  side 
with  these  maladies,  yet  not  showing  the  typical  pathological  events 
which  attend  them,  or  showing  them  to  so  faint  a  degree  as  to  baffle  the 
judgment  of  the  observer.  Further  observations,  conducted  with  great 
care  and  analyzed  in  sufficient  numbers,  are  needed  to  determine  the  no- 
sological relations  of  such  cases.  It  is  probable  that  they  are  not  of  non- 
specific origin  in  most  instances,  but  that,  by  reason  of  the  smallness  of 
the  dose  of  the  fever-producing  poison,  or  an  imperfect  susceptibility  on 
the  part  of  the  individual,  the  specific  fever  is  of  such  mildness  that  its 
characteristic  phenomena  are  not  made  manifest — it  is,  in  other  words, 
"  abortive."  Cases  of  this  kind  do  not  correspond  to  the  definition  of 
simple  continued  fever.  These  views  have  led  some  observers  to  deny 
even  the  existence  of  the  fever  under  consideration  as  a  distinct  affection. 
Practitioners  of  medicine  in  every  clime  are  familiar  with  the  fever  called, 
from  its  transient  character,  ephemera  and  febricula.  From  a  duration 
of  one,  two,  or  three  days,  which  is  common,  this  fever  may,  without  other 
modification,  in  rare  examples,  be  extended  over  a  period  of  ten  or  twelve 


2  THE    CONTINUED    FEVERS. 

days.  It  is  therefore  proper  to  include  under  the  heading,  simple  fever 
or  simple  continued  fever,  all  essential  continued  fevers  that  are  clearly 
of  non-specific  origin,  whether  they  be  in  the  strict  sense  of  the  term 
ephemeral,  or  be  prolonged  through  several  days.  As  Flint '  has  pointed 
out,  the  diminutive  term  febricula  has  relation  to  the  duration  of  the  fever 
rather  than  to  its  intensity.      In  many  instances  the  fever  is  intense. 

While  the  affection  known  as  sunstroke  is  properly  referred  in  sys- 
tematic treatises  to  the  diseases  of  the  nervous  system,  Professor  H,  C. 
Wood  '  has  shown  that  its  phenomena  are  those  of  fever  of  great  intensity, 
and  that  the  continued  fever  following  exposure  to  the  sun  or  to  a  pro 
longed  high  temperature,  differs  from  sunstroke  in  degree  and  not  in  kind. 
The  terms  sun  fever  and  heat  fever,  are  therefore  properly  applicable  to 
the  febrile  affections  brought  about  by  the  action  of  these  causes. 


Etiology. 

It  results,  from  what  has  been  already  said,  that  only  those  fevers  can 
be  regarded  as  simple  that  are  due  to  non-specific  causes — that  are,  in 
fact,  neither  contagious  nor  miasmatic.  It  is  also  important,  theoretically 
and  in  practice,  to  exclude  all  symptomatic  fevers,  such  as  the  fever  which 
follows  traumatism  and  surgical  procedures,  the  formation  of  abscesses, 
other  local  inflammations,  and  hectic  fever.  It  is  indeed  the  more  impor- 
tant because  in  frequent  instances  the  symptomatic  fever  bears  a  strong 
clinical  resemblance  to  ephemera.  This  discrimination  is  important  on 
theoretical  grounds,  because  the  one  is  secondary  to  and  dependent  upon 
a  primary  disorder  of  which  it  is  no  more  than  a  symptom,  the  constitu- 
tional disturbance  resulting  from  local  irritation  ;  whilst  the  other  is  in 
itself  the  primary  disease  and  the  result  of  causes  affecting  the  nervous 
system  at  large  witliout  determinable  local  lesion.  It  is  important  in 
practice,  by  reason  of  its  obvious  influence  upon  diagnosis  and  treat- 
ment. 

Many  different  causes  are  known  to  be  capable  of  producing  the  train 
of  febrile  phenomena  which  constitutes  simple  continued  fever.  Among 
them  may  be  named  exposure  to  great  heat  or  cold,  excesses  in  eating 
and  drinking,  mental  and  bodily  fatigue,  excitement  and  violent  emo- 
tions. Children,  by  reason  of  the  relative  instability  of  their  nervous 
organization,  are  much  more  prone  to  this  form  of  fever  than  adults.  It 
is  a  malady  more  frequently  encountered  in  summer  than  at  other  seasons 
of  the  year,  and  is  often  produced  by  the  fatigues  of  travel  and  unwonted 
exposure  to  the  sun.  It  is  not  unfrequently  due  to  the  combined  influ- 
ence of  the  excitement,  the  physical  exhaustion,  and  the  exposure  to  the 


'  Clinical  Medicine.     1879. 

•  Sunstroke  and  Thermic  Fever.     Boylstou  Prize  Essay,  1871. 


SIMPLE    CONTINUED    FEVER.  6 

direct  ravs  of  a  mid-day  sun,  which  are  attendant  npon  surf-bathing. 
Many  cases  of  simple  continued  fever  occurred  in  Philadelphia  at  the 
time  of  the  Centennial  Exhibition  in  1876.  Citizens  and  strangers  were 
alike  exposed  to  the  action  of  some  of  the  most  powerful  causes  of  non- 
specific fever.  The  summer  was  unusually  hot,  the  distances  to  be  tra- 
versed were  considerable,  the  fatigue  of  several  successive  days  spent  on 
the  grounds  of  the  exhibition  was  often  beyond  the  sight-seer's  powers  of 
endurance.  Add  the  excitement  of  mingling  with  vast  throngs  of  en- 
thusiastic people,  and  at  evening  a  hunger  out  of  proportion  to  the  di- 
gestive powers  of  jaded  men  and  women,  and  it  seems  remarkable  not 
that  cases  of  fever  occurred  as  often  as  they  did,  but  that  they  were  so 
comparatively  rare. 

Clinical  History. 

Simple  fever  begins  abruptly.  Prodromes  are  absent.  Lassitude,  a 
chill  or  chilliness,  and  a  sudden  rise  in  temperature,  mark  the  onset  of  the 
disease.  All  the  phenomena  of  fever  are  rapidly  established.  Hot  skin, 
rapid  pulse,  thirst,  headache,  pain  in  the  back  and  limbs,  harass  the  patient 
from  the  beginning.  The  bowels  are  constipated,  the  urine  diminished 
in  quantity,  and  of  high  specific  gravity.  Except  in  cases  due  to  excesses 
at  table,  and  the  like,  vomiting  is  uncommon.  There  is  loss  of  appetite. 
The  tongue  is  white  and  coated.  The  rise  in  temperature  is  not  only  very 
rapid,  it  is  also  in  many  cases  very  great.  In  the  course  of  a  few  hours 
it  may  reach  39.4°  C.  (103°  F.)  or  even  40.5°  C.  (105°  F.).  The  abruptness 
of  the  temperature  rise,  and  the  rapidity  with  which  the  maximum  is 
reached  are  characteristic  of  this  fever  as  compared  with  the  other  con- 
tinued fevers,  with  the  exception  of  relapsing  fever.  They  are  only 
shared  in  by  some  forms  of  malarious  fever  (intermittent),  variola,  measles, 
and  pneumonia.'  The  continuance  of  the  fever  is  usually  of  short  dura- 
tion. In  a  few  "hours,  or  a  single  day,  defervescence  sets  in  and  the  tem- 
perature speedily  falls  to  the  standard  of  health — an  instance  of  crisis. 
On  the  other  hand,  the  fever  may  be  prolonged  through  two,  three,  four,  or, 
as  has  been  pointed  out  above,  to  ten  or  twelve  days,  the  normal  body-heat 
being  regained  by  several  days  of  gradual  defervescence — li/sis. 

The  defervescence  is  often  marked  by  copious  perspiration,  but  this 
is  not  always  the  case.  It  is  sometimes  attended  by  vomiting  or  diarrhoea, 
by  a  copious  deposit  of  lithates  in  the  urine,  or  by  epistaxis,  or  hemorrhage 
from  the  uterus  or  rectum.' 

Simple  continued  fever  is  attended  by  no  constant  or  characteristic 
eruption. 


'  Aitken  :  Science  and  Practice  of  Medicine.     Third  American  edition.     1873. 
-  Murchison  :  The  Continued  Fevers  of  Great  Britain.     Second  edition.     1873. 


4  TU.K    CONTINUED    FEVERS. 

An  eruption  of  liorj)es  about  tlie  lips  and  nostrils  is  often  observed 
at  the  close  of  the  attack.      Convalescence  is  rapid. 

Murchison  describes  four  varieties  of  this  form  of  fever,  as  follows : 

I.  Abrupt  seizure  with  chills  or  rigors  ;  the  febrile  action  high  ;  quick, 
full  pulse  ;  hot  skin  ;  white,  furred  tongue  ;  great  thirst,  and  no  appetite  ; 
constipation;  scanty,  high-colored  urine;  intense  headache,  with  sometimes 
restlessness,  sometimes  drowsiness  ;  pains,  as  from  bruises,  in  the  limbs. 
The  attack  comes  to  an  end  in  twelve,  twenty -four,  or  thirty -six  hours,  and 
is  properly  called  Ephemera. 

II. ,  The  pyrexia  is  occasionally  prolonged  over  several  days — rarely, 
however,  exceeding  ten.  The  pulse  is  frequent,  full,  hard,  and  bounding  ; 
thirst  and  the  heat  of  skin  are  intense  ;  headache  is  sharp  and  distressing; 
delirium  sometimes  occurs.  Termination  abrupt,  with  copious  perspira- 
tion. This  is  the  Synocha,  or  Inflammatory  Fever  of  English  writers  of 
the  last  century.  It  is  separable  from  ephemera  only  by  the  difference  in 
duration. 

III.  The  Ardent  Continued  Fever  of  the  tropics,  as  observed  by 
Dr.  Murchison  among  the  European  troops  at  Calcutta  in  1853,  and  in 
Burmah  in  1854,  appeared  to  be  merely  an  exaggerated  form  of  the  now 
rare  synocha  of  Britain.  Young,  plethoric  persons  not  yet  acclimated  were 
chiefly  attacked.  The  fever  prevailed  during  the  hot,  dry  months,  when 
the  mercury  usually  ranged  from  33.3°  C.  (92°  F.)  to  41°  C.  (10G°  F.)  and 
never  fell  below  29°  C.  (84°  F.).  The  symptoms  in  many  cases  com- 
menced after  incautious  exposure  to  the  sun.  A  chill,  or  occasionally 
nausea  and  vomiting,  ushered  in  the  attack.  To  these  speedily  succeeded 
the  frequent,  full  pulse,  burning  skin,  flushed  face,  giddiness,  intense 
headache,  ringing  in  the  ears,  intolerance  of  light,  restlessness,  and  sleep- 
lessness, which  mark  a  difference  from  synocha  in  degree  rather  than  any 
difference  in  kind.  Abovit  the  fourth  or  fifth  day  active  delirium  set  in, 
followed  by  more  or  less  unconsciousness,  with  contracted  pupils  and 
sometimes  complete  coma.  Between  the  sixth  and  ninth  days  death  took 
place,  the  patient  remaining  comatose  to  the  end,  or  a  copious  perspira- 
tion occurred,  followed  by  an  increased  flow  of  urine  depositing  copious 
urates,  and  convalescence.  The  subsidence  of  the  fever  was  in  some  in- 
stances followed  by  sudden,  or  even  fatal  collapse. 

IV.  The  term  Asthenic  Simple  Fever  is  suggested  by  Dr.  Murchison 
for  a  variety  of  the  form  of  continued  fever  under  consideration,  in  which 
the  febrile  action  is  less  intense  and  the  duration  more  prolonged  than  in 
the  varieties  above  mentioned.  The  patient  loses  appetite  and  strength; 
the  pulse  is  frequent,  but  rather  feeble  than  tense  ;  the  tongue  is  slightly 
furred;  the  bowels  are  confined;  some  headache  is  present,  and  sleep  is 
disturbed.  These  symptoms  may  extend  over  a  period  of  two  or  three 
weeks  without  change,  except  as  regards  the  patient's  strength,  which 
gradually  fails.     Such  attacks  have  been  known  to  follow  «rreat  bodilv  or 


SIMPLE    CONTINUED    FEVER.  0 

mental  fatigue.  It  is  to  be  borne  in  mind  that  these  cases  are  never  fatal, 
and  that  enteric  fever  often  presents  the  collection  of  symptoms  just  de- 
scribed. 

The  following  case,  observed  and  narrated  by  Prof.  Flint,  is  a  typical 
example  of  febricula  as  it  is  usually  seen  in  childhood  in  the  United 
States  : 

A  child,  six  or  seven  years  of  age,  while  playing  out  of  doors,  apparently  in  perfect 
health,  at  noontime  complained  of  illness  and  was  taken  home.  Soon  afterward  the 
axillary  temperature  was  104"  F.  There  was  no  evidence  of  any  local  affection;  no 
remedies  were  prescribed.  At  midnight  the  fever  was  diminished,  after  seven  hours 
it  was  slight,  and  at  noon  the  thermometer  showed  absence  of  fever.  There  was  no 
return  of  the  febrile  condition,  although  no  preventive  treatment  was  employed,  and 
the  usual  health  was  at  once  regained. 


Analysis  of  Symptoms. 

The  temperature. — The  suddenness  of  the  rise  —  and  the  rapidity  with 
which  the  maximum,  39.4°  C.  (103°  F. )  or  40.5°  C.  (105°  F.),  is  reached,  have 
been  pointed  out.  In  cases  terminating  by  well-marked  crisis  with  criti- 
cal discharges,  either  in  the  common  form  of  copious  perspiration  or  from 
the  bowels,  the  decline  of  the  temperature  is  never  so  rapid  as  its  oncom- 
ing. In  cases  of  longer  duration  the  fall  usually  takes  the  form  of  a  pro- 
longred  and  o^radual  defervescence. 

The  circulation. — The  pulse  is  in  almost  all  cases  frequent  and  full. 
In  the  severer  forms  it  is  usually  tense  and  binding. 

The  digestive  system. — The  tongue  is  white,  furred;  thirst  is  constant, 
often  distressing  ;  loss  of  appetite  is  usually  complete  ;  the  bowels  are,  as 
a  rule  from  which  there  is  little  variation,  constipated  till  the  termina- 
tion of  the  attack;  vomiting,  save  in  cases  brought  about  by  excesses  in 
eating  or  drinking,  and  occasionally  at  the  onset  of  the  severe  variety  of 
the  fever  met  with  in  the  tropics,  is  uncommon;  it  occurs  in  some  cases 
as  the  febrile  action  subsides. 

The  ttrine. — It  is  diminished  in  quantity,  dark  in  color,  and  of  very 
high  specific  gravity,  1030-1035,  with  increase  of  solids,  and  particularly 
of  urea.  It  presents  the  very  type  of  febrile  urine.'  With  the  decline  of 
the  temperature  the  volume  of  urine  speedily  augments,  and  copious  de- 
posits of  urates  occur.  Albuminuria  does  not  occur.  In  six  cases,  exam- 
ined by  Parkes,  throughout  the  whole  course  of  the  disease  the  urine  was 
never  albuminous. 

Tlie  skill. — The  face  is  flushed,  the  surface  hot  and  dry.  There  is  no 
characteristic  eruption.     Occasionally  an  erythematous  blush  is  to  be  ob- 

'  Parkes  on  the  Urine.     1860. 


b  THE    CONTINUED    FEVERS. 

served   upon   the   loins  and  thighs;    it  disappears  with    the  fever.     The; 
eruption  of  herpes  upon  the  lips  and  nose  is  so  common  at  the  close  of] 
simple  continued  fever  that  this  disease  has  by  some  persons  been  called 
Herpetic  J'ever. 

7'Ae  nervous  si/stem. — Chills  or  rigors  are  rarely  absent  at  the  onset,] 
except  in  young  children.     Headache  is  a  constant  symptom.    It  is  acutej 


Fig.  1.— Temperature  in  Simple  Continued  Fever.     (Wuuderlich.) 


Fig.  2.— Teiiipcrat\iro  in  Simple  Continued  Fever  ;  more  gradual  defervescence.     (.Wunderlich.) 


in  character,  and  is  sometimes  described  as  throbbing  or  darting.  It  is  in 
severe  cases  intense.  Delirium  may  follow  it.  Restlessness  and  sleep- 
lessness are  cominon  ;  on  tlie  other  hand,  the  patient  is  in  some  instances 
dull  and  drowsy.     ]n  the  variety  above  described  as  the  ardent  fever  of 


SIMPLE    CONTINUED    FEVER.  7 

hot  climates,  giddiness,  intense  headache,  ringing  in  the  ears,  intolerance 
of  light,  muscae  volitantes,  restlessness  and  inability  to  sleep,  pass  into 
delirium,  to  be  followed  by  stupor  with  contracted  pupils,  and  this  con- 
dition may  deepen  into  coma,  in  which  the  patient  dies. 

Duration. 

The  whole  sickness,  as  in  the  case  of  the  child  seen  by  Prof.  Flint, 
a,bove  narrated,  frequently  does  not  last  more  than  a  few  hours.  Its  du- 
ration, in  the  mild  form  of  simple  continued  fever  usually  encountered  in 
the  temperate  climates,  is  from  three  or  four  to  six  days,  rarely  longer 
than  ten.  Several  cases  seen  by  the  writer  in  the  summer  of  1876,  in 
Philadelphia,  came  to  an  end  with  free  perspiration  about  the  sixth  day. 
The  variety  characterized  by  less  active  fever,  and  described  as  asthenic, 
may  continue  two  or  three  weeks. 

Diagnosis. 

It  is  obvious,  from  what  has,  been  stated,  that  the  diagnosis  of  simple 
■continued  fever  cannot  in  all  instances  be  positively  established.  This 
statement  is  not  only  true  of  the  disease  when  seen  early,  but  it  is  also 
true  in  some  cases  after  the  fever  has  come  to  its  close  and  the  patient 
has  regained  his  health.  A  doubt,  arising  from  the  absence  of  sufficient 
evidence,  must  under  some  circumstances  remain  in  the  mind  of  the  can- 
did practitioner  as  to  whether  the  case  has  been  in  fact  a  simple  non-spe- 
cific fever,  or  a  mild,  abortive,  not  well-characterized  instance  of  one  of  the 
specific  fevers.  In  order  to  arrive  at  a  satisfactory  diagnosis  of  simple  con- 
tinued fever,  the  following  considerations  are  to  be  taken  into  account: 

The  occurrence  of  the  fever  after  events  that  are  thought  to  be  ade- 
<[uate  to  cause  it,  as  exhausting  over-exertion,  exposure  to  heat,  excesses 
at  table,  and  the  like. 

The  absence  of  any  discoverable  local  inflammation,  or  of  the  history 
of  any  recent  injury. 

The  abrupt  beginning,  without  prodromes;  the  rapid  temperature-rise. 
The  early  severity  of  the  febrile  symptoms,  commonly  greater  at  the  com- 
mencement than  in  either  enteric  fever  or  typhus,  may  sometimes  aid  in 
diagnosis. 

The  duration,  commonly  short. 

The  absence  of  eruption. 

Constipation  and  the  absence  of  the  abdominal  symptoms  of  enteric 
fever. 

The  absence  of  joint-pains,  of  jaundice,  of  the  enlargement  of  the 
liver  and  spleen,  which  are  early  present  in  relapsing  fever. 

Its  sporadic  occurrence  and  the  absence  of  epidemic  diseases. 


THE    CONTINUED    FEVERS. 


Prognosis  and  Mortality. 

The  prognosis  of  simple  continued  fever  in  temperate  climates  is  in 
the  highest  degree  favorable  as  regards  a  complete  recovery.  Death 
rarely  if  ever  occurs.  There  are  no  sequels,  and  perfect  convalescence  is 
rapid.  Deaths  reported  as  due  to  this  cause  are  probably  the  result  of 
enteric  fever  with  latent  abdominal  symptoms.  In  the  tropics  simple 
fever  becomes  a  formidable  and  frequently  fatal  disease. 

The  post-mortem  examinations  conducted  by  Dr.  Murchison  in  India 
revealed  "  great  congestion  of  all  the  internal  organs,  particularly  of  the 
lungs,  liver,  and  spleen.  The  right  side  of  the  heart  vv^as  full  of  firmly 
coagulated  blood.  The  sinuses  of  the  brain,  and  the  pia  mater  vpere  also 
very  vascular,  and  occasionally  there  was  an  increased  amount  of  intra- 
cranial fluid." 

Martin'  speaks  of  "congestive  states  of  the  cerebro-spinal  organs." 
No  characteristic  lesions  are  met  with. 

Treatment. 

The  diagnosis  of  simple  continued  fever  being  established,  no  special 
treatment  is  required  in  temperate  climates.  The  disease  tends  to  recov- 
ery. Neither  complications  nor  sequels  are  apt  to  occur.  The  sufferings 
of  the  patient  may  be,  however,  greatly  mitigated  b}'^  judicious  sympto- 
matic treatment. 

A  purge,  to  be  followed  by  saline  diaphoretics  and  diuretics,  may  be 
ordered.  Sponging  the  surface  with  cold  water,  or  vinegar  mingled  with 
water,  is  grateful.  If  the  arterial  excitement  be  great,  with  a  full,  bound- 
ing pulse  and  throbbing  head,  aconite  may  be  given  in  the  form  of  the 
tincture  of  the  root,  gtt.  j. — iij.,  q.  s.  h.,  the  effect  upon  the  pulse  being 
closely  watched.  Restlessness  and  vigil  may  be  relieved  by  the  bromides 
or  by  chloral  hydrate  in  gramme  doses  (gr.  xv.),  p.  r.  n.  Thirst  calls  for 
the  unstinted  use  of  the  alkaline  aerated  waters,  Apollinaris,  seltzer, 
Vichy,  carbonic  acid  water;  weak  iced  tea  with  lemon-juice  is  an  ac- 
ceptable draught.  By  reason  of  the  short  duration  of  the  fever  in  most 
cases,  the  supporting  diet  is  not  called  for;  custards,  blanc-mange,  jellies, 
and  light  broths,  are  all  that  the  patient  requires  till  with  the  deferves- 
cence appetite  returns. 

The  happiest  results  have  seemed  to  follow,  in  my  own  practice,  the 
treatment  of  ephemera  and  febricula  in  children  by  purgation,  followed 
by  the  frequently  repeated  administration  of  small  doses  of  chloral  hy- 
drate 0.06 — 0.20  gramme  (gr.  j. — iij.)  quoque  hora  vel  q.  s.  h.,  with  cool 

'James  Renald  Martin,  F.R.S.:  The  Influence  of  Tropical  Climates.  Ne-w  edi- 
tion.   1856. 


SIMPLE    CONTINUED    FEVER.  9 

drink  as  craved.  But  it  is  to  be  borne  in  mind  that  the  inherent  tendency 
of  the  sickness  is  to  a  speedy,  and — as  compared  with  other  fevers — an 
abrupt  termination,  and  that  its  course  is  in  childhood  ahnost  always  of 
brief  duration,  so  that  the  most  guarded  deductions  are  to  be  drawn  as  to 
the  apparent  success  attending  measures  of  treatment  aimed  at  cutting 
short  the  duration  of  the  attack.  There  exists  no  doubt  of  the  value  of 
treatment  in  alleviating  the  urgency  of  some  of  the  more  distressing 
symptoms. 

Quinine,  the  mineral  acids,  a  nutritious,  readily  digested  diet,  and  wine 
are  indicated  in  the  so-called  asthenic  variety  of  simple  continued  fever. 

The  ardent  fever  of  the  tropics  demands,  from  its  intense  pyrexia  and 
the  urgency  of  the  danger  to  life,  energetic  anti-pyretic  measures.  Cold 
affusion — the  effect  upon  the  temperature  being  carefully  watched,  ice- 
water  enemata,  quinine,  digitalis,  jaborandi,  are  remedies  that  would  ap- 
pear to  be  most  likely  to  do  good  in  a  disease  often  fatal  by  the  very  in- 
tensity and  persistence  of  the  fever-process,  and  the  effect  of  the  high 
temperature  upon  the  tissues  of  the  body,  and  more  particularly  upon  the 
blood  and  the  nervous  system.  This  variety  of  simple  fever  is  scarcely 
less  closely  allied  to  sunstroke  in  its  pathology  than  in  its  causation,  and 
demands,  in  fact,  analogous  therapeutic  measures. 


n. 

INFLUENZA. 

Definition. — A  continued  fever,  usually  of  mild  intensity,  occurring 
only  in  widely  extended  epidemics,  and  due  to  a  specific  cause;  it  is 
essentially  characterized  by  early  catarrh  of  the  mucous  membrane 
of  the  respiratory  tract,  and  in  many  cases  also  of  the  digestive  tract; 
by  quickly  oncoming  debility  out  of  proportion  to  the  intensity  of 
the  fever  and  the  catarrhal  processes;  and  by  serious  nervous  symp- 
toms. There  is  a  strong  tendency  to  inflammatory  complications, 
especially  of  the  lungs;  uncomplicated  cases  are  rarely  fatal  except 
in  feeble  and  aged  persons.  The  attack  does  not  confer  immunity 
from  the  disease  in  future  epidemics. 

Synonyms. — Febris  catarrhalis;  Defluxio  catarrhalis  epidemicus;  Catar- 
rhus  a  contagio;  Rheuma  epidemicum;  Cephalalgia  contagiosa;  Epi- 
demic catarrhal  fever;  Tac;  Horion;  Quinte;  Coqueluche;  Ladendo, 
also  written  La  Dando;  Baraquette;  Generale;  Coquette;  Cocote; 
Allure;  Follette;  Petite  poste;  Petit  courier;  Grenade;  La  grippe; 
Ziep;  Schaffhusten  and  Schaffkrankheit  ;  Huhner  Weh;  Blitz-Ka- 
tarrh;  Modefieber;  Mai  del  Castrone.  There  are  also  several  names 
indicating  its  supposed  origin;  thus,  it  has  been  called  in  Russia 
"Chinese  catarrh;"  in  Germany  and  Italy,  "the  Russian  disease;" 
in  France,  "  Italian  fever,"  "  Spanish  catarrh,"  and  so  forth. 

Of  these  names  several  are  scientific,  but  the  most  are  popular.  The 
latter  seem  to  be  in  many  instances  the  more  expressive  and  important. 
It  is  indeed  a  remarkable  fact  that  in  two  instances  at  least  the  popular 
name  for  the  disease  under  consideration  has  found  its  way  widely  into 
medicine  and  medical  literature,  almost  to  the  exclusion  of  the  studied 
terms  by  which  science  has  sought  to  designate  it;  these  are  "  influenza" 
and  "  La  grippe." 

I  have  omitted  from  the  list  of  synonyms  such  obsolete  and  now 
meaningless  terms  as  Peripneumonia  notha  (Sj'denham,  Boerhaave),  Peri- 
pneumonia   catarrhalis  (Huxham),  Pleuritis  humida  (Stoll),  as  being  of 


INFLUENZA.  11 

interest  rather  to  the  student  of  medical  history  than  to  the  student  of 
medicine. 

Febris  catarrhalis,  defluxio  catarrhalis,  catarrhus  epidemicus,  rheuma 
epidemicum,  are  terms  which  retain  with  difficulty  the  place  given  them 
in  the  literature  of  influenza  by  the  medical  authorities  of  a  past  century. 

Catarrhus  a  contagio  (Cullen)  and  cephalalgia  contagiosa  are  derived 
from  a  view  of  the  nature  of  the  disease  which  has  been  the  cause  of  much 
controversy,  and  which  must,  as  will  be  shown  farther  on,  be  now  re- 
garded as  settled  by  a  compromise. 

Epidemic  catarrhal  fever  is,  with  its  Latin  equivalent,  perhaps  the 
most  satisfactory  of  the  so-called  scientific  names  for  the  disease. 

In  the  popular  names  for  the  affection  there  is  to  be  noted  an  indica- 
tion of  the  natural  character  of  some,  at  least  of  the  peoples  who  have 
suffered  from  its  frequent  visitation.  Among  the  English  it  is  known  as 
cold,  or  epidemic  cold,  or,  in  deference  to  medical  authority,  as  catarrh, 
or  epidemic  catarrh,  and  at  present,  both  among  the  folk  and  with  doc- 
tors, as  influenza.  Englishmen  are  not  then  either  quick  to  see  in  the 
disease  a  resemblance  to  some  common  circumstance  or  thing,  nor  are 
they  disposed  to  make  a  joke  about  it. 

The  Germans  find  obvious  resemblances.  In  the  labored  respiration 
and  the  character  of  the  cough  they  find  a  suggestion  of  a  common  epi- 
zootic affecting  the  sheep;  hence  Schaffhusten  (sheep-cough)  and  Schaff- 
krankheit  (sheep-sickness);  or,  because  the  cough  is  like  the  crowing  of  a 
cock  and  the  disturbance  of  respiration  and  the  rapid  prostration  suggest 
some  resemblance  to  a  common  disease  of  the  domestic  fowl,  it  has  been 
called  Huhner  Weh  (chicken-disease,  whooping-cough),  and  Ziep,  which  is 
about  equivalent  to  "  pip."  They  call  it  also,  from  its  rapid  invasion, 
Blitz-Katarrh  (lightning  catarrh)  and  Modefieber  (the  fever  in  vogue). 

But  the  French  make  a  jest  of  everything,  and  the  more  serious  the 
subject  the  better  the  joke.  Hence,  they  have  found  a  new  name  for 
almost  every  great  epidemic  of  influenza,  and  each  more  trivial  than  the 
last.  Hence,  tac  (rot);  horion  (in  jest,  a  blow);  quinte,  because  the  spells 
recur  at  intervals  of  five  hours  (sic) ;  coqueluche  (a  hood,  or  cowl),  from  the 
cap  worn  by  those  suffering  from  the  malady;  and  so  on  through  the  long 
list  given  above. 

La  grippe  is  from  the  Polish  chrypka  (Raucedo) ;  it  is  thought,  how- 
ever, by  some  writers,  to  be  derived  from  agripper  (to  seize). 

Influenza  is  of  Italian  derivation.  It  is  said  that  the  disease  received 
this  name  because  it  was  attributed  to  the  "  influence  "  of  the  stars,  or 
from  a  secondary  signification  of  the  word  indicating  something  fluid, 
transient,  or  fashionable. 


12  THE    CONTINUED    FEVERS. 


Historical  Sketch. 


Epidemics  of  influenza  have  been  clearly  recorded  only  since  the  be- 
ginning of  the  sixteenth  century.  There  are  numerous  accounts  of  earlier 
epidemic  diseases  resembling  it,  but  they  are  neither  sufficiently  particu- 
lar nor  distinctive  to  warrant  us  in  inferring  its  undoubted  existence 
from  them.  It  is  supposed  to  be  referred  to  by  Hippocrates,  who  yet 
gives  no  exact  description.'  An  outbreak  in  the  Athenian  array  in  Sicily 
(415  B.C.),  recorded  by  Diodorus  Siculus,  has  been  supposed  to  he  influ- 
enza. In  spite  of  these  statements,  and  those  of  others  to  the  effect  that 
it  is  a  disease  known  from  a  remote  antiquity,  it  may  be  said  that  no 
accounts  can  be  confidently  established,  as  referring  to  the  disease  now 
known  as  influenza,  in  the  writings  of  classical  antiquity." 

As  early  as  the  ninth  century  several  epidemics  of  catarrhal  fever, 
Italian  fever  and  the  like,  which  were  probably  influenza,  were  made  mat- 
ter of  history.  In  the  year  a.d.  837,  a  cough,  which  spread  like  the 
plague,  was  recorded.  In  876  there  appeared  in  Italy  a  similar  epidemic, 
which  spread  rapidly  over  all  Europe.  It  is  related  that  dogs  and  birds 
suffered  with  symptoms  not  unlike  those  characterizing  the  affection  in 
man.  In  976,  Germany  and  all  France  suffered  from  a  fever  of  which 
the  chief  symptom  was  cough.  No  epidemic  is  noted  until  two  centuries 
later,  when,  in  1173,  a  widespread  malady,  of  which  the  symptoms  were 
chiefly  catarrhal,  raged  in  Europe  ;  while  less  important  epidemics  of  a 
like  character  are  recorded  as  having  occurred  during  the  following  cen- 
tury (1239-1299). 

Parkes  states  that  in  the  fourteenth  century  there  are  to  be  found 
records  of  six  epidemics,  and  in  the  fifteenth  seven  great  visitations  of 
influenza  are  described. 

Aitken  *  speaks  of  a  very  fatal  prevalence  of  influenza  throughout 
France  in  1311,  and  of  an  epidemic  in  1403,  in  which  the  mortality  was  so 
great  that  the  courts  of  law  in  Paris  were  closed  in  consequence  of  the 
deaths. 

Influenza  is  mentioned  in  the  "  Annals  of  the  Four  Masters"  as  hav- 
ing prevailed  in  Ireland  in  the  fourteenth  century,  and  a  disease,  ex- 
pressed by  similar  symptoms,  is  alluded  to  in  early  Gaelic  manuscripts 
under  the  name  of  Creatan  (creat,  the  chest).  The  disease  is  described 
also  in  an  Irish  manuscript  of  the  fifteenth  century,  under  the  terms  Fu- 
acht  and  Slaodan.* 

The  first  epidemic  that  prevailed  in  the  British  Isles,  of  which  any  ac- 

'  Parkes  :  Reynolds'  System  of  Medicine,  vol.  i.  1868. 

*  Zuelzer  :  Ziemssen's  Cyclopajdia  of  Medicine,  vol.  ii.  1875. 
^  Aitken's  Practice  of  Medicine,  vol.  i.     1872. 

*  Theophilus  Thompson  :  Annals  of  Influenza.     1852. 


INFLUENZA.  13 

curate  description  remains,  is  that  of  the  year  1510.  The  disease  came 
from  Malta  and  invaded  first  Sicily,  then  Italy  and  Spain  and  Portugal, 
whence  it  crossed  the  Alps  into  Hungary  and  Germany  as  far  as  the 
Baltic  Sea,  extending  westward  into  France  and  Britain.  Its  track 
•widened  over  the  whole  of  Europe  from  the  southeast  to  the  extreme 
northwest,  and  it  is  said  that  not  a  single  family  and  scarce  a  person  es- 
caped it.  It  was  attended  by  "  a  grievous  pain  in  the  head,  heaviness,  diffi- 
culty of  breathing,  hoarseness,  loss  of  strength  and  appetite,  restlessness, 
retchings  from  a  terrible  tearing  cough.  Presently  succeeded  a  chilli- 
ness, and  so  violent  a  cough,  that  many  were  in  danger  of  suffocation. 
The  first  day  it  was  without  spitting  ;  but  about  the  seventh  or  eighth 
day  much  viscid  phlegm  was  spit  up.  Others  (though  fewer)  spat  only 
water  and  froth.  When  they  began  to  spit,  cough  and  shortness  of 
breath  were  easier.  None  died  except  some  children.  In  some  it  went 
off  with  a  looseness  ;  in  others  by  sweating.  Bleeding  and  purging  did 
hurt,"  '  Blisters  were  commonly  employed  ;  two  each  upon  the  arms  and 
legs,  and  one  to  the  back  of  the  head. 

The  description  of  influenza  is  sufficiently  clear  to  place  the  nature  of 
this  epidemic  beyond  all  doubt. 

The  epidemic  of  1557,  starting  westward  from  Asia,  spread  over 
Europe  and  then  crossed  the  Atlantic  to  America.  It  circumnavigated 
the  globe.  The  malady  broke  out  in  England  after  a  season  of  unusual 
rain  and  a  period  of  great  scarcity  of  corn,  in  the  month  of  September. 
"  Presently  after  were  many  catarrhs,  quickly  followed  by  a  most  severe 
cough,  pain  of  the  side,  difficulty  of  breathing,  and  a  fever.  The  pain  was 
neither  violent  nor  pricking,  but  mild.  The  third  day  they  expectorated 
freely.  The  sixth,  seventh,  or  at  the  farthest  the  eighth  day,  all  who  had 
that  pain  of  the  side,  died  ;  but  such  as  were  blooded  on  the  first  or 
second  day,  recovered  on  the  fourth  or  fifth  ;  but  bleeding  on  the  last 
two  days  did  no  service."  "  Some,  but  very  few,  had  continual  fevers 
along  with  it  ;  many  had  double  tertians;  others  simple  slight  intermit- 
tent. All  were  worse  by  night  than  by  day;  such  as  recovered  were  long 
valetudinary^,  had  a  weak  stomach  and  hypped."  Gravid  women  either 
aborted  or  died.  This  epidemic  spread  with  frightful  rapidity.  Thousands 
were  attacked  at  the  same  moment.  The  entire  population  of  Nismes, 
with  scarcely  an  exception,  fell  ill  of  it  upon  the  same  day.  It  was  ex- 
tremely fatal.  In  Mantua  Carpentaria,  a  small  town  near  Madrid,  it  broke 
out  in  August,  and  so  fatal  was  the  bloodletting  and  purging  which  con- 
stituted the  treatment  at  first,  that  of  the  two  thousand  persons  who 
were  bled,    all   died.'^       The  disease  raged  in  some  parts  till  the  middle 


'  Thomas  Short :  A  General  Chronological  History  of  the  Air,  Weather,  Seasons, 
Meteors,  etc.     London,  1749.     Quoted  in  the  Annals  of  Influenza. 
■  Dr.  Short :  loc.  cit. 


14  THE    CONTINUED    FEVERS. 

of  the  following  year  (1558),  and  carried  off,  in  Delph  alone,  five  thou- 
sand of  the  poor.  In  all  cases  mild  treatment  was  called  for,  with  warm 
broths  and  speedy  immersals  "  to  recall  the  appetite,  and  keep  the  vessels 
of  the  throat  open." 

In  1580  a  great  epidemic  of  influenza  spread  from  the  southeast  to- 
ward the  northwest  over  Asia,  Africa,  and  Europe.  From  Constantino- 
ple and  Venice  it  overran  Hungary  and  Germany,  and  reached  the 
farthest  regions  of  Norway,  Sweden,  and  Russia.  It  spread  into  England, 
and  has  been  described  by  Dr.  Short,  In  Italy  it  prevailed  during  Au- 
gust and  September,  in  England  from  the  middle  of  August  to  the  end 
of  September,  and  in  Spain  during  the  whole  summer.  In  most  places 
its  duration  was  about  six  weeks.  As  a  rule  the  termination  was  favora- 
ble, although  the  disease  ran  a  somewhat  protracted  course.  In  the  ac- 
count of  Dr.  Short  it  is  stated  that  "  few  died  except  those  that  were 
let  blood  of,  or  had  unsound  viscera."  In  some  places,  on  the  contrary, 
the  course  of  the  disease  was  very  severe.  In  Rome  two  thousand  died 
of  it,  according  to  the  author  just  cited,  but  Zuelzer  informs  us  that  the 
victims  of  this  epidemic  in  the  Eternal  City  were  not  less  than  nine  thou- 
sand, and  adds  that  Madrid  must  have  been  almost  depopulated  by  it. 
This  high  mortality  has  been  attributed  to  the  bloodletting  practised  in 
the  treatment  of  the  disease.  The  symptoms  were  similar  to  those  of  the 
previous  epidemics,  with  a  greater  shortness  of  breath,  which  continued 
in  many  cases  for  some  time  after  the  disappearance  of  the  catarrhal 
trouble.     There  was  great  sweating  at  the  end  of  the  attack. 

The  plague,  measles,  and  small-pox  prevailed  also,  and  with  consider- 
able violence  during  the  year  1580.' 

The  disease,  unfelt  for  several  years,  reappeared  in  Germany  in  1591; 
an  epidemic,  extending  from  Holland  through  France  and  into  Italy, 
occurred  in  1593;  in  IGIO,  catarrh  is  said  to  have  prevailed  throughout 
Europe.  In  1626-27,  epidemic  catarrhal  fever  made  its  appearance  in 
Italy  and  France;  in  1G42-43,  in  Holland;  in  1647,  in  Spain  and  in  the  col- 
onies of  the  Western  World,  and  again  in  1655,  in  North  America. 

According  to  Webster,'  this  epidemic  of  1647  was  the  first  catarrh 
mentioned  in  American  annals. 

In  1658  and  1675,  it  again  visited  Austria,  Germany,  England,  etc. 
The  first  of  these  two  epidemics  is  described  by  Willis,'  and  the  second 
by  Sydenham,''  as  they  occurred  in  England,  and  the  accounts  are  to  be 

'  Theophilus  Thompson  :  Annals  of  Influenza. 

■  Noah  Webster  :  A  Brief  History  of  Epidemic  and  Pestilential  Diseases.  London, 
1800. 

^  Dr.  Willis  :  The  Description  of  a  Catarrhal  Fever  Epidemical  in  the  Middle  of  the 
Spring  in  the  Year  1058.     Practice  of  Physic.     1684. 

■•  The  Epidemic  Coughs  of  the  Year  1675,  with  the  Pleurisy  and  Peripneumony  that 
supervened.     From  the  Works  of  Thomas  Sydenham,  M.D. 


INFLUENZA.  15. 

found  in  the  already  oft-quoted  "Annals  of  Influenza,"  It  is  about  this- 
period  that  the  disease  began  to  be  known  as  influenza,  and  it  is  not 
without  interest  to  observe  that  the  "  influence  "  of  the  stars  suggested  it- 
self, in  connection  with  its  sudden  appearance  and  wide  prevalence,  to 
the  minds  of  the  physicians  of  this  date.  Willis  writes  that  "  about  the 
end  of  April  (1658),  suddenly  a  distemper  arose,  as  if  sent  by  S07ne  blast 
of  the  stars,  which  laid  hold  on  very  many  together;  that  in  some  towns, 
in  the  space  of  a  week,  above  a  thousand  people  fell  sick  together," 

Epidemics  are  recorded  as  having  occurred  in  Great  Britain  and' 
Europe  in  1688,  1693,  and  in  1709,  The  disease  raged  in  1713  widely 
over  Europe  from  Denmark  to  Italy. 

In  1729-30,  a  widespread  epidemic  swept  over  Europe.  In  five  months 
it  extended  over  Russia,  Poland,  Germany,  Sweden,  and  Denmark.  In 
Vienna  sixty  thousand  persons  fell  ill  of  it.  In  the  autumn  it  spread  to 
England,  and  reached  France  and  Switzerland  ;  from  there  it  extended 
to  Italy,  and  by  February  it  had  reached  Rome  and  Naples.  Spain  did- 
not  escape  its  ravages,  and  it  is  said  to  have  found  its  way  to  Mexico. 
The  symptoms  did  not  differ  in  any  important  respect  from  those  already 
described  as  characterizing  previous  epidemics.  Pains  in  the  limbs  and 
fever  marked  the  onset  of  the  attack;  catarrh,  oppression,  hoarseness, 
cough,  followed.  In  some  cases,  delirium,  drowsiness,  and  faintings  oc- 
curred. A  petechial  eruption  was  observed,  in  some  instances,  between 
the  fourth  and  seventh  days.  Zuelzer  suggests  that  spotted  fever  may 
have  prevailed  at  the  same  time.  Turbid  urine,  copious  sweats,  bilious- 
stools,  and  nose-bleeding  were  often  noted.  In  Switzerland,  only  children- 
and  old  persons  died.     The  disease  was  not  very  fatal. 

Two  years  later  (1733-33)  an  epidemic,  starting  from  Saxony  and 
Poland,  overran  Germany,  Switzerland,  and  Holland,  and  invaded  Great 
Britain  in  the  month  of  December,  Toward  the  end  of  January  it  spread 
in  a  southeasterly  direction  to  France,  Italy,  Spain,  and  westward  to- 
North  America,  thence  southward  to  the  islands  of  the  West  Indies,  and 
on  to  South  America,  The  course  of  the  disease  in  this  epidemic  was 
favorable.  It  terminated  in  from  three  to  fourteen  days,  with  sweating,, 
bleeding  from  the  nose,  or  an  abundant  discharge  from  the  nasal  passages. 
The  aged  and  those  suffering  from  chronic  pulmonary  diseases  mostly 
perished.  In  Scotland  three  forms  of  the  affection  were  described,  namely: 
the  cephalic,  the  thoracic,  and  the  abdominal.  The  epidemic  slowly  spread 
over  Eastern  Europe  and  in  a  southeasterly  direction,  and  may  be  said  to 
have  lasted  till  1737. 

Concerning  this  epidemic,  John  Huxham,  of  Plymouth,  wrote  as  fol- 
lows : '    "  About  this  time  a  disease  invaded  these  parts,  which  was  the 

'  Observations  on  the  Air  and  Epidemical  Diseases.  Translated  from  the  Latin.. 
London,  1758. 


16  THE    CONTINUED    FEVERS. 

most  completely  epidemic  of  any  I  remember  to  have  met  with  ;  not  a 
house  was  free  from  it;  the  beggar's  hut  and  the  nobleman's  palace  were 
alike  subject  to  its  attacks,  scarce  a  person  escaping  either  in  town  or 
country;  old  and  young,  strong  and  infirm,  shared  the  same  fate."  The 
malady  had  raged  in  Cornwall  and  the  western  parts  of  Devonshire  from 
the  beginning  of  February;  it  reached  Plymouth  on  the  10th,  which  was 
on  a  Saturday,  and  that  day  numbers  were  suddenly  seized.  The  next 
day  multitudes  were  taken  ill,  and  by  the  18th  or  20th  of  March  scarcely 
any  one  had  escaped  it. 

"The  disorder  began  at  first  with  a  slight  shivering;  this  was  presently 
followed  by  a  transient  erratic  heat  and  headache,  and  a  violent  and 
troublesome  sneezing;  then  the  back  and  lungs  were  seized  with  flying 
pains,  which  sometimes  attacked  the  heart  likewise,  and  though  they  did 
not  long  remain  there,  yet  were  very  troublesome,  being  greatly  irritated 
by  the  violent  cough  which  accompanied  the  disorder,  in  the  fits  of  which 
a  great  quantity  of  a  thin,  sharp  mucus  was  thrown  out  from  the  nose 
and  mouth.  These  complaints  were  like  those  arising  from  what  is  called 
catching  cold,  but  presently  a  slight  fever  came  on,  which  afterward  grew 
more  violent;  the  pulse  was  now  very  quick,  but  not  in  the  least  hard  and 
tense  like  that  in  a  pleurisy;  nor  was  the  urine  remarkably  red,  but  very 
thick,  and  inclining  to  a  whitish  color;  the  tongue,  instead  of  being  dry, 
was  thickly  covered  with  a  whitish  mucus  or  slime;  there  was  an  universal 
complaint  of  want  of  rest  and  a  great  giddiness.  Several  likewise  were 
seized  with  a  most  racking  pain  in  the  head,  often  accompanied  by  a  slight 
delirium.  Many  were  troubled  with  a  tinnitus  auriwn,  or  singing  in  the 
ears;  and  numbers  suffered  from  violent  earaches,  or  pains  in  the  meatus 
auditorius,  which  in  some  turned  to  an  abscess.  Exulcerations  and 
swellings  of  the  fauces  were  likewise  very  common.  The  sick  were  in 
general  very  much  given  to  sweat,  which,  when  it  broke  out  of  its  own 
accord,  was  very  plentiful,  and  continued  without  striking  in  again,  and 
did  often  in  the  space  of  two  or  three  days  wholly  carry  off  the  fever. 
You  have  here  a  description  of  this  epidemic  disease  such  as  it  prevailed 
hereabouts,  attacking  every  one  more  or  less;  but  still,  considering  the 
great  multitude  that  were  seized  by  it,  it  was  fatal  to  but  few,  and  that 
chiefly  infants  and  consumptive  old  people.  It  generally  went  off  about 
the  fourth  day,  leaving  behind  a  troublesome  cough,  which  was  very  often 
of  long  duration,  and  such  a  dejection  of  strength  as  one  would  hardly 
have  suspected  from  the  shortness  of  the  time. 

"  On  the  whole,  this  disorder  was  rarel}'  mortal,  unless  by  some  very 
great  error  arising  in  the  treatment  of  it;  however,  this  very  circumstance 
proved  fatal  to  some,  who,  making  too  slight  of  it,  either  on  account  of  its 
being  so  common,  or  not  thinking  it  very  dangerous,  often  found  asthmas, 
hectics,  or  even  consumptions  themselves,  the  forfeitures  of  their  incon- 
siderate rashness." 


INFLUENZA.  17 

Arbuthnot  also  described  this  visitation  of  the  disease.'  He  regarded 
the  uniformity  of  the  symptoms  in  every  place  as  most  remarkable,  and 
tells  us  that,  during  the  whole  season  in  which  it  prevailed,  there  was  "  a 
great  run  of  hysterical,  hypochondriacal,  and  nervous  distempers;  in  short, 
all  the  symptoms  of  relaxation."  Most  observers  looked  upon  the  con- 
tinued changes  of  temperature  as  active  in  producing  this  widespread  and 
long-continued  epidemic. 

During  the  years  1737-38,  influenza  again  swept  over  England,  North 
America,  the  islands  of  the  West  Indies,  and  France  ;  in  1742-43,  it  pre- 
vailed in  Western  Europe  and  the  British  Isles  ;  in  1757-58,  in  North 
America,  the  West  Indies,  France,  and  Scotland.  In  1761,  it  overran  the 
North  American  Colonies  and  the  West  Indies. 

The  epidemic  of  1762  extended  very  generally  over  Europe  and  Great 
Britain.  In  Germany  nine-tenths  of  the  population  were  attacked  by  the 
disease. 

Widely  extended  epidemics  prevailed  in  Europe  and  America  in  1767 
and  1775;  in  1772  it  raged  in  North  America ;  in  1778-80  in  France,  Ger- 
many, and  Russia.  Noah  Webster  found  influenza  prevalent  in  North 
America  in  1781;  the  next  year,  one  of  the  most  remarkable  epidemics 
of  this  disease  (described  as  the  epidemic  of  1782)  appeared  in  Europe. 
It  came  from  the  East,  from  Asia  into  Russia.  From  St.  Petersburg  it 
spread  during  the  winter  and  spring  over  Sweden,  Germany,  Holland,  and 
France.  In  the  autumn  it  was  in  Italy,  Spain,  and  Portugal.  The  crews 
of  Dutch  and  English  ships  were  taken  ill  with  the  disease  upon  the  high 
seas. 

In  Vienna  three-fourths  of  the  population  fell  ill  of  it  with  such  sud- 
denness that  it  got  here  for  the  first  time  its  name  of  "  Blitz-katarrh  " 
(lightning  catarrh).  It  was  characterized  by  great  pain  in  the  back, 
breast,  and  throat,  and  by  extraordinary  enfeeblement.  Relapses  occurred, 
and  inflammation  of  the  lungs  and  bowels  were  common.  Children  re- 
mained relatively  exempt  from  its  seizure.  This  epidemic  broke  out  in 
England  about  the  end  of  April,  and  raged  until  the  end  of  June.  "The 
duration  of  the  malady  in  some  was  not  above  a  day  or  two  ;  but  it  usu- 
ally lasted  near  a  week  or  longer.  In  a  few  the  symptoms  seemed  to 
abate  in  two  or  three  days,  but  some  returned  and  raged  with  more  vio- 
lence than  at  first."  "  The  disease  was  not  regarded  as  in  itself  fatal,  and 
few  could  be  said  to  have  died  of  it,  "  but  those  who  were  old,  asthmatic, 
or  who  had  been  debilitated  by  some  previous  indisposition."  Yet  its  in- 
fluence upon  the  weekly  bills  of  mortality  in  London,  where  it  made  its 

'  An  Essay  Concerning  the  Effects  of  Air  on  Human  Bodies.     London,  1751. 

^  An  Account  of  the  Epidemic  Disease  called  the  Influenza  of  the  Year  1783. 
Collected  from  the  Observations  of  several  Physicians  in  London  and  in  the  Country, 
by  a  Committee  of  the  Fellows  of  the  Royal  Colleges  of  Physicians  in  London.  Read 
at  the  College,  June  25,  1783. 


18 


THE    CONTINUED    FEVERS. 


appearance  between  May  12th  and  18th,  was  so  great  that  it  seems  worth 
while  to  transfer  the  record  from  the  report  of  the  College  of  Physicians 
to  these  pages. 

The  total  weekly  returns  stand  thus  : 


Tuesday,  May  7th 299 

"  "  14th 307 

"  "  21st 33G 

"  <'  28th 390 

"       June  4th 385 


Tuesday,  June  11th 560 

"  "     18th 437 

"     25th 434 

«        July  2d 296 


Numerous  recurring  outbreaks  took  place  in  Europe  and  America  dur- 
ing the  years  1788-90.  One  of  these,  as  it  occurred  in  America,  is  well 
described  by  Dr.  John  Warren,'  of  Boston,  in  a  letter  to  Lettsom.  This 
letter  is  dated  May  30,  1790,  and  among  other  matters  of  great  interest 
respecting  the  disease,  it  is  stated  that  "  Our  beloved  President  Washing- 
ton is  but  now  on  the  recovery  from  a  very  severe  and  dangerous  attack 
of  it  in  that  city  "  (New  York). 

Webster  mentions  an  epidemic  in  America  in  1790,  one  in  Europe  in 
1795,  and  another  in  Europe  in  1797;  but  there  seems  to  have  been  no 
general  epidemic  of  sufficient  importance  to  attract  the  attention  of  other 
writers  upon  the  subject  until  1798,  when  the  malady  again  broke  out  in 
Russia  and  spread  over  the  greater  part  of  Europe,  continuing  to  prevail  in 
various  regions  till  1803,  when  it  again  appeared  in  England,  and  is  de- 
scribed by  several  writers  of  that  country. 

From  1805  to  1827,  influenza  prevailed  (according  to  Zuelzer,  who  tells 
us  that  few  years  during  this  interval  were  free  from  it)  in  frequently  re- 
curring epidemics  in  Europe  and  America.  Thompson  mentions  no  visi- 
tation in  England  between  1803  and  1831. 

In  the  year  1830,  began  a  series  of  epidemics  remarkable  for  their  wide 
diffusion  and  the  rapid  succession  with  which  they  followed  one  upon  an- 
other. The  disease  began  in  China;  in  September  it  reached  the  Indian 
Archipelago;  it  swept  into  Russia,  and  invaded  Moscow  in  November  ;  in 
January,  1831,  it  was  raging  in  St.  Petersburg  ;  March  found  it  in  Warsaw; 
April  in  Eastern  Prussia  and  Silesia;  in  May  it  prevailed  in  Denmark, 
Finland,  and  a  great  part  of  Germany,  and  in  the  same  month  it  fell  upon 
Paris  ;  in  June  it  affected  England  and  Sweden  ;  it  still  was  creeping 
about  Middle  Europe,  and  lingering  in  Great  Britain  at  the  end  of  July; 
in  the  early  winter  it  swept  southward  into  Italy,  and  westward  across  the 
Atlantic  to  North  America,  and  was  still  harassing  the  inhabitants  of  cer- 
tain regions  of  the  United  States  in  January  and  February,  1832.  Mean- 
while it  continued  in  the  East,  spreading  to  Java,  Farther  India,  and  the 


'  Thomas  Joseph  Pettigrew ; 
LettBom.    1817. 


Memoirs  of  the  Life  and  Writings   of  J.  Coakley 


INFLUENZA.  19 

Indian  Archipelago.  It  continued  in  Hindostan  after  it  had  died  out  in 
Europe.  But  in  January,  1833,  it  again  visited  Russia  and  rolled  thence 
southward  and  eastward  over  the  most  of  Europe.  It  is  recorded  that  by 
February  it  had  reached  Galicia  and  Eastern  Prussia;  in  March  it  was  in 
Prussia,  Bohemia,  and  Warsaw,  and  had  extended  to  Syria  and  Egypt;  in 
April  to  many  parts  of  Germany  and  Austria,  and  to  France  and  Great 
Britain.  Midsummer  found  the  disease  yet  prevailing  in  some  districts  of 
Germany  and  Northern  Italy,  and  in  the  early  autumn  it  was  in  Switzer- 
land and  Eastern  France;  in  November  it  visited  Naples.  Epidemics  so 
frequent,  so  widespread,  and  so  unsparing  of  individuals  wherever  the  dis- 
ease appeared,  could  not  fail  to  excite  a  deep  and  general  interest.  From 
this  period  the  literature  of  the  subject  has  been  voluminous. 

A  brief  period  of  repose  ensued.  For  three  years  no  epidemic  occurred 
which  was  of  sufficient  importance  to  attract  the  attention  of  medical  his- 
torians. 

In  December,  1837,  influenza  reappeared,  and  first,  as  so  often  before, 
in  Russia;  Sweden  and  Denmark  were  almost  simultaneously  affected; 
in  January,  1837,  it  broke  out  in  London,  and  rapidly  swept  over  all 
England,  and  into  France  and  Germany.  In  January  it  appeared  in  Ber- 
lin and  shortly  afterward  in  Dresden,  Munich,  and  Vienna.  The  disease 
spread  by  February  into  Switzerland,  and  into  Spain  as  far  as  Madrid  by 
the  end  of  March.  In  London  almost  the  whole  population  was  attacked, 
and  the  mortality  was  enormous.  Dr.  Bryson '  states  that  the  deaths 
were  quadrupled  during  the  prevalence  of  the  disease.  Large  populations 
suffered  most. 

This  epidemic  spread  into  the  southern  hemisphere  and  prevailed  at 
the  same  time,  and  consequently  at  exactly  the  opposite  season  that  it 
prevailed  north  of  the  equator,  in  Sydney  and  at  the  Cape  of  Good  Hope. 

From  1837  till  1850-51,  numerous  epidemics  of  influenza  occurred. 
Few  years  were  exempt  from  them.  The  epidemic  of  1847-48  has  been 
described  by  many  writers,  and  more  particularly,  as  it  occurred  in  Lon- 
don, by  Peacock  '  with  great  exactitude.  It  is  estimated  that  one-fourth 
of  the  entire  population  of  that  city  were  more  or  less  affected  by  the  dis- 
ease. The  epidemic  prevailed  in  London  for  six  months,  and  although 
the  deaths  registered  for  the  entire  period,  as  from  influenza,  amounted 
to  only  one  thousand  seven  hundred  and  thirty-nine,  it  is  stated  in  the 
report  of  the  Registrar-General  that  during  the  six  weeks  the  epidemic 
was  at  its  height,  not  less  than  five  thousand  persons  died,  in  the  metro- 
politan districts,  in  excess  of  the  average  mortality  of  the  period,  the  ex- 
cess showing   itself  in   nearly  every  class  of  disease;  the   local  maladies 

'  Annals  of  Influenza. 

'  Thomas  Berill  Peacock,  M.D.  :  On  the  Influenza,  or  Epidemic  Catarrhal  Fever  of 

1847-48.     1848. 


j 


20  THE    CONTINUED    FEVEKS. 

which  had  been  the  predominant  affections  being  doubtless,  in  many  cases, 
assigned  as  the  cause  of  death. 

This  epidemic  affected  between  one-fourth  and  one-half  of  the  popu 
lation  of  Paris,  and  in  Geneva  the  proportion  of  those  attacked  was  not 
less  than  one-third  of  the  entire  population. 

More  or  less  widespread  epidemics  of  influenza  are  recorded  as  having' 
occurred  in  1857-58  and  1800  ;  in  1864  in  Switzerland  ;  in  1867  in  Paris 
in  the  spring ;  and  at  various  times  in  the  United  States  and  Canada 

A  mild  epidemic  occurred  in  1874,  in  Berlin, 

Influenza  prevailed  over  a  wide  area  in  the  United  States  during  the 
early  months  of  1879.  The  characteristics  of  this  visitation  have  been 
well  described  by  Da  Costa.* 

For  the  most  part  the  disease,  since  the  great  epidemic  of  1847-48,  has 
affected  a  smaller  proportion  of  the  inhabitants  of  the  localities  visited, 
and  has  run  a  less  dangerous  course  than  in  the  epidemics  previously  de- 
scribed. It  has  for  this  reason  occupied  a  less  conspicuous  place  in  the 
medical  literature  of  recent  years.  It  is  nevertheless  true  that  even  in  the 
mildest  epidemics,  w^hen  a  relatively  small  number  of  persons  are  seized, 
and  the  symptoms  are  in  most  cases  almost  insignificant,  cases  do  here  and 
there  occur  which  are  of  a  serious  or  even  fatal  character,  and  that  the 
death-rate  from  other  diseases  is  for  the  time  considerably  increased. 

Affections  of  a  catarrhal  kind  have  frequently  prevailed  among  the 
domestic  animals  at  the  same  time  that  influenza  has  been  epidemic. 
Horses,  dogs,  and  cats  are  subject  to  these  disorders;  neat  cattle,  goats 
and  sheep  have  been  more  rarely  affected;  chickens  and  pheasants  have 
suffered,  and  it  is  stated  by  some  of  the  older  writers  that  birds,  and  par- 
ticularly the  sparrow,  have  deserted  localities  in  which  influenza  was  pre- 
vailing, while  migratory  birds  have  taken  flight  earlier  than  usual. 

These  epizootics  have  sometimes  preceded  the  appearance  of  influenza 
among  men  by  a  period  of  some  weeks  or  days,  in  other  instances  they 
have  appeared  contemporaneously;  and  in  a  widespread  outbreak  among 
horses  in  the  United  States  in  1873,  in  which  the  symptoms  and  morbid 
anatomy,  accurately  observed,  were  undoubtedly  those  of  influenza,  *  the 
disease  did  not  affect  man  except  to  a  very  limited  extent.  A  want  of 
fulness  of  description,  and  the  inaccuracy  of  diagnosis  common  in  the 
consideration  of  general  diseases  of  the  lower  animals,  leave  the  precise 
nature  of  most  of  the  epizootics  described  by  the  earlier  writers  in  great 
uncertainty. 

An  extensive  but  mild  influenza  has  prevailed  as  an  epizootic,  chiefly 

'  The  Prevailing  Epidemic  of  Influenza — Its  Characteristic  Phenomena — Pulmonary, 
Gastro-intestinal— Cerebral  and  Nervous — Its  wide  Distribution,  Mortality,  and  Treat- 
ment.    Medical  and  Surgical  Reporter.     Philadelphia,  March  8,  1879. 

2  F.  Woodbury,  M.D.  :   Morbid  Anatomy  of  the  Epizootic.      Philadelphia  Medica 
Times,  December  14,  1872. 


I 


INFLUENZA.  21 

affecting  horses,  during  the  latter  part  of  the  summer  and  the  autumn  of 
1880,  in  Canada  and  the  United  States  east  of  the  Mississippi  River.  Dogs 
were  also  affected,  but  less  generally,  and  human  beings  to  a  still  slighter 
extent.  In  several  localities  where  this  invasion  of  the  disease  was  ob- 
served by  the  writer,  the  horses  were  first  affected,  the  dogs  next,  and  after 
the  lapse  of  some  weeks,  as  the  animals  were  recovering,  it  became  epi- 
demic; but  those  persons  who  took  care  of  horses,  and  were  much  in  con- 
tact with  them,  neither  suffered  earlier  nor  more  severely  than  others  not 
so  exposed. 

Etiology. 

1.     Predisposing  Causes. 

Large  as  has  been  the  place  in  medical  literature  occupied  by  the 
histories  of  epidemics  of  influenza,  the  nature  of  the  "  epidemic  influ- 
ence "  which  gives  rise  to  the  disease  is  still  unknown. 

There  are  no  well-established  facts  upon  which  to  base  the  existence 
of  individual  peculiarities  that  may  be  regarded  as  predisposing  causes. 
When  the  disease  appears,  a  large  proportion  of  the  population  is  attacked 
without  distinction  of  age,  sex,  social  condition,  or  occupation.  Previous 
illness,  whether  acute  or  chronic,  local  or  constitutional,  affords  no  pro- 
tection. 

Aged  and  infirm  persons,  and  those  of  nervous  temperament,  are 
thought  to  be  especially  liable  to  attack;  but  the  robust  possess  no  immu- 
nity. All  races  and  dwellers  in  every  climate  are  the  victims  of  influenza. 
In  a  community  invaded  by  the  disease,  females  are  apt  to  be  the  first  at- 
tacked, the  adult  males  next,  and  the  children  last.  It  has  been  observed 
that  in  some  epidemics  children  are  but  little  liable  to  be  attacked. 

An  attack  in  one  epidemic  confers  no  exemption  from  the  disease  in 
another  epidemic,  and,  independently  of  relapses,  which  are  not  infre- 
quent, persons  have  been  known  to  experience  a  second  attack  during  the 
prevalence  of  the  same  epidemic. 

Persons  dwelling  in  overcrowded  and  ill-ventilated  habitations,  and  in 
low,  damp,  and  unhealthy  situations,  have  in  certain  epidemics  especially 
suffered,  and,  according  to  the  report  of  the  Registrar-General,  the  increase 
of  deaths  by  influenza  during  the  epidemic  of  1847,  in  England,  was 
much  greater  in  the  districts  in  which  there  is  ordinarily  a  high  mortality 
than  in  healthier  places.  This,  as  Dr.  Parkes  observes,  must  indicate 
greater  prevalence  or  greater  severity  of  the  disease. 

Influenza  appears  at  all  seasons  of  the  year,  and  affects  every  latitude, 
though  it  is  somewhat  more  common  in  cold  climates.  It  has  no  connec- 
tion with  known  atmospheric  conditions.  Many  of  the  earlier  writers 
sought  to  establish  a  causative  relation  between  low  temperatures  and 
sudden  variations  of  temperature  and  influenza,   and,  by  reason  of  the 


22  THE    CONTINUED    FEVERS. 

confusion  in  the  minds  of  the  people  between  the  disease  and  common 
"colds,"  there  has  always  existed  an  opinion  that  such  a  relation  obtains. 
There  is  no  evidence  to  sustain  this  view,  and  all  the  later  writers  upon 
this  subject  concur  in  the  statement  that  neither  low  temperature  nor 
abrupt  changes  give  rise  to  the  affection.  It  has  prevailed  in  hot  and 
dry  seasons,  in  the  West  Indies,  on  the  sea-coast  of  Java,  in  India,  in 
Egypt,  at  the  Cape  of  Good  Hope,  in  the  Riviera  in  summer. 

The  condition  of  the  air,  as  regards  moisture  or  dryness,  does  not  influ- 
ence the  spread  of  the  disease.  It  has  occurred  at  sea,  on  low  sea-coasts, 
and  in  the  dry  air  of  Upper  Egypt. 

Prolonged  east  and  northeast  winds  have  often  prevailed  at  the  time 
of  influenza.  This  fact  is  in  accord  with  the  observation  that  many  epi- 
demics have  extended  from  east  to  west  and  southwest,  as,  for  example, 
from  Russia  over  Europe.  The  spread  of  the  disease  is,  however,  not  in- 
fluenced greatly  by  local  winds.  It  does  not  move  with  the  same  velocity, 
and  even  sometimes  moves  against  them.  In  several  well-authenticated 
instances  a  dense  and  foul  fog  has  preceded  or  attended  the  outbreak  of 
epidemics.  The  much  greater  number  of  epidemics  that  have  occurred 
altogether  without  such  manifestations  make  it  in  the  highest  degree 
probable  that  this  has  been  a  coincidence.  Ozone  in  large  quantities, 
artificially  produced,  may  give  rise  to  the  symptoms  of  ordinary  catarrh, 
but  it  is  not  a  cause  of  influenza.  The  disease  is  not  in  any  way  con- 
nected with  the  condition  of  the  soil,  elevation,  volcanic  eruptions,  or  any 
other  local  cause.  The  history  of  every  epidemic  goes  to  prove  this  state- 
ment. Moreover,  without  this  assumption,  its  diffusion  over  whole  coun- 
tries and  continents — indeed,  over  several  quarters  of  the  globe — would  be 
beyond  our  comprehension. 

Before  taking  up  the  consideration  of  the  exciting  causes  of  influenza, 
it  is  necessary  to  state  the  known  facts  concerning  the  march  of  epidem-' 
ics  and  the  spread  of  the  disease  in  affected  localities.  It  has  prevailed 
with  greater  or  less  frequency  in  most  parts  of  the  world.  Epidemics 
have  recurred  at  irregular  periods.  It  was  at  one  time  thought  that  the 
course  of  the  disease  was  cyclical,  with  a  return  at  intervals  of  about  one 
hundred  years.  This  view  was  long  ago  proved  to  be  unfounded.  About 
every  twenty-five  or  thirty-five  years  great  epidemics  have  swept  over  vast 
areas  of  the  globe,  and  influenza  may  be  said  to  be,  at  such  times,  pan- 
demic. Less  widely  extended  epidemics  have  taken  place  with  greater  or 
less  frequency  in  the  intervals  of  the  great  outbreaks.  But  it  is  not 
possible  to  establish  anything  like  a  cycle  by  which  the  returns  of  the 
disease  are  governed. 

It  has  been  supposed  in  some  instances  to  prevail  within  restricted 
localities,  as,  for  example,  in  a  single  city,  but  it  is  probable  that  such 
local  epidemics  are  due  to  local  causes,  and  that  they  are  of  the  nature  of 
simple  ordinary  catarrhal  fever,  rather  than  true  influenza. 


INFLUENZA.  23 

The  epidemics  extend  in  great  areas,  usually  in  a  direction  from  the 
east  or  northeast  toward  the  west  and  south.  At  other  times  they  take 
the  opposite  direction,  and  in  some  years  they  have  appeared  to  radiate 
in  various  directions  from  several  centres.  It  is  in  consequence  of  these 
facts  in  reo-ard  to  the  spread  of  influenza,  that  two  views  have  arisen  in 
the  minds  of  scientific  men  concerning  the  origin  of  the  affection.  The 
first  of  these  is  that  each  epidemic  starts  out  from  some  single  unknown 
source,  and  spreads  thence  from  point  to  point,  invading  more  distant  lo- 
calities successively  as  it  advances,  until  at  length  it  dies  out  in  regions 
most  remote  from  the  starting-point.  This  opinion  is  in  accord  with  the 
popular  belief.  Thus,  the  Italians  have  called  it  the  German  disease;  the 
Germans,  the  Russian  pest;  the  Russians,  the  Chinese  catarrh;  and  the 
geographical  relation  of  these  nations  indicate  the  usual  track  of  the  great 
epidemics,  as  shown  in  the  foregoing  historical  sketch. 

The  other  opinion  is  that  it  arises  not  from  a  single  place,  but  may 
start  anywhere,  and  that  a  widespread  epidemic  may  be  due  to  the  suc- 
cessive outbreak  at  many  distinct  points  of  origin. 

The  evidence  that  the  great  epidemics  of  influenza  are  due  to  some  gen- 
eral and  pandemic  influence,  is  to  my  mind  conclusive.  The  point  of 
origin  of  the  great  epidemics  has  not  yet  been  indicated  with  precision, 
and  must  remain  beyond  conjecture  until  further  facts  bearing  upon  the 
question  of  their  source  are  brought  to  light. 

When  it  has  prevailed  over  a  large  portion  of  the  earth's  surface,  its 
progress  from  place  to  place  has  usually  been  rapid.  In  this  respect,  how- 
ever, the  epidemics  show  a  great  diversity.  It  sometimes  travels  exceed- 
ingly slowly.  It  is  said  to  have  overrun  Europe  in  six  weeks,  and  it  has 
again  taken  six  months  to  do  so.  It  sometimes  attacks  places  widely 
remote  from  each  other  within  short  intervals  of  time,  and  it  has  appeared 
at  the  same  time  in  different  quarters  of  the  globe.  It  does  not  follow 
the  great  lines  of  travel  and  commercial  intercourse. 

When  the  influenza  enters  a  city,  it  continues  to  prevail,  as  a  rule,  from 
four  weeks  to  two  months,  but  exceptionally  it  remains  a  longer  time;  for 
example,  the  epidemic  of  1831  was  prevalent  in  Paris  for  the  greater  part 
of  a  year.  It  in  all  instances  finally  disappears,  and  sporadic  cases  do 
not  occur  in  the  intervals  of  the  epidemics. 

In  rare  instances,  however,  the  epidemics  are  heralded  by  sporadic 
cases.  But  commonly  they  seize  simultaneously  upon  numbers  of  the  in- 
habitants of  affected  districts,  so  that,  when  the  epidemic  is  severe,  the 
sick  are  in  a  short  time  to  be  counted  by  thousands,  and  business  is  par- 
alyzed as  by  a  blow.  They  rapidly  reach  their  height  and  subside  almost 
as  suddenly  as  they  began.  In  a  large  city  the  disease  frequently,  per- 
haps always,  makes  its  appearance  nearly  at  the  same  time  in  several 
different  localities,  affecting  certain  streets  and  quarters  solely  or  more 
generally  than  others  for  a  time,  and  spreading  thus  from  several  centres 


24  THE    CONTINUED    FEVERS. 

through  the  entire  community.  Large  towns  and  cities  are  generally 
affected  earlier  than  the  villages  around  them,  and  the  latter,  though 
closely  adjacent,  sometimes  escape  for  weeks. 

The  crews  of  ships  upon  the  high  seas,  not  sailing  from  an  infected 
port,  are  said  to  have  suffered  from  the  seizure,  and  epidemics  have  crossed 
the  Atlantic  from  the  Old  World  to  the  New,  and  in  some  instances  in 
the  opposite  direction. 

2.     The  Exciting  Cause. 

The  question  of  the  contagiousness  of  influenza  is  one  of  grave  interest, 
and  has  been  the  subject  of  much  controversy.  The  great  rapidity  of  the 
spread  of  epidemics,  the  vast  areas  they  overrun,  the  fact  that  they  do  not 
follow  the  lines  of  human  intercourse,  the  suddenness  with  which  great 
numbers  of  the  inhabitants  of  an  invaded  district  or  city  are  seized,  the 
fact  that  the  most  complete  seclusion  from  intercourse  with  affected 
persons,  or  even  the  shutting  up  of  houses,  affords  in  most  instances  no 
protection  whatever,  all  go  to  show  that  the  disease  spreads,  in  the  main, 
independently  of  direct  contact,  and  this  opinion  has  been  almost  univer- 
sally entertained.  On  the  other  hand,  there  is  evidence  to  show  that  the 
disease  is  to  some  extent  contagious;  and  so  convincing  have  the  facts 
bearing  upon  this  point  appeared  to  some,  that  they  have  believed  it  to  be 
propagated  entirely  by  human  intercourse.  Haygarth '  declares,  as  the 
result  of  his  observations  during  the  epidemics  of  1775  and  1782,  that  the 
influenza  spreads  "  by  the  contagion  of  patients  in  the  distemper;  "  and 
Falconer,'  writing  of  the  epidemic  of  1803,  says,  "  I  have  no  doubt  that  it 
is  contagious  in  the  strictest  sense  of  the  word."  Watson  ^  regards  the 
instances  in  which  the  complaint  has  first  broken  out  in  those  particular 
houses  of  a  town  at  which  travellers  have  arrived  from  infected  places,  as 
too  numerous  to  be  attributed  to  mere  chance.  Very  often  those  dwell- 
ing near  the  invalids  are  attacked  next  in  the  order  of  time,  and  when 
the  disease  affects  a  household  all  do  not  usually  manifest  the  symptoms 
at  the  same  time,  but  one  member  after  another  is  stricken  down  with  it. 

In  some  rare  cases  the  isolation  or  seclusion  of  a  community  has  ap- 
peared to  give  protection,  as  in  cloisters,  prisons,  garrisons,  and  the  like  ; 
at  all  events,  there  are  instances  on  record  where  segregated  communities 
of  this  kind  have  escaped  attack.  This  is,  however,  merely  negative  evi- 
dence, and  cannot  carry  conviction. 

'  John  Haygarth,  M.D.,  F.R.S.  :  On  the  Planner  in  which  the  Influenza  of  1775 
and  1782  Spread  by  Contagion  in  Chester  and  its  Neighborhood. 

'William  Falconer,  M.D. .  F.R.S.:  An  Account  of  the  Epidemic  Catarrhal  Fever, 
Commonly  called  the  Influenza,  as  it  appeared  at  Bath  in  the  Winter  and  Spring  of  the 
Year  1803.     Bath,  1803. 

'  Principles  and  Practice  of  Medicine. 


INFLUENZA.  25 

A  recent,  carefully  conducted  observation,  under  somewhat  unusual 
circumstances,  shows  that  influenza  may  be  brought  from  an  infected  city 
in  such  a  way  as  to  give  rise  to  a  localized  outbreak  in  a  remote  commu- 
nity, in  which,  however,  the  disease,  in  the  instance  under  consideration, 
did  not  become  epidemic. 

Drs.  Guiteras  and  White  '  narrate  that,  influenza  prevailing  in  Europe, 
and  particularly  in  Paris  and  London,  an  American  gentleman  in  bad 
health  contracted  the  disease  in  London,  improved,  suffered  a  relapse 
shortly  afterward  in  Paris,  and  died  there  at  the  end  of  December,  1879. 
His  body  was  embalmed  and  sent  home.  Following  the  exposure  of  the 
remains  of  this  person  to  the  view  of  his  family  in  Philadelphia,  there 
was  an  outbreak  of  influenza  with  characteristic  symptoms,  which  affected, 
in  the  first  place,  members  of  that  family;  afterward,  friends  living  in 
close  intercourse  with  them,  next  the  medical  attendants  of  some  of  them, 
and  finally  the  housekeeper,  and  a  patient  or  two  of  one  of  the  physicians 
who  wrote  the  paper,  the  whole  number  affected  in  Philadelphia  being 
eighteen,  at  the  time  of  the  publication  of  the  account.  Subsequently 
two  or  three  other  cases  were  developed,  but  the  disease  did  not  extend 
beyond  the  immediate  circle  of  those  in  direct  communication  with  the 
invalids. 

Between  those  holding  the  opinion  that  influenza  is  not  contagious, 
and  those  imbued  with  the  opposite  view,  there  must  be,  it  seems  to  me — 
regard  being  had  to  the  foregoing  facts — a  compromise  of  the  question 
which  is  to  be  based  upon  the  degree  of  contagiousness.  This  will  be 
conceded  by  all  modern  authorities  to  be  but  slight. 

Influenza  has  been  supposed  to  develop  at  once  without  a  period  of 
incubation,  persons  in  perfect  health  being  struck  down  with  it  as  by 
lightning-stroke.  It  is  now  ascertained  that  a  period  of  incubation,  vary- 
ing from  a  few  hours  to  several  days,  and  usually  without  subjective 
symptoms,  exists.  Numerous  instances  are  recorded  in  which  persons 
coming  into  an  infected  city  have  remained  well  for  one,  two,  or  three 
days,  but  have  eventually  shared  the  sufferings  of  those  into  whose  midst 
they  had  come.  There  are  cases  also  in  which  the  period  of  incubation 
could  not  have  been  less  than  two  or  three  weeks.  There  is  no  sufficient 
evidence  of  a  genetic  or  causal  relation  between  influenza  and  any  other 
epidemic  disease.  The  statement  that  other  prevalent  diseases  abate  in 
frequency  and  intensity  upon  its  outbreak,  is  not  borne  out  by  well-ob- 
served facts.  Graves  ^  holds  that  those  suffering  with  acute  diseases  are 
less  liable  during  the  febrile  stage,  but  that  they  are  attacked  as  conva- 
lescence sets  in. 

'  John  Guiteras,  M.D.,  and  J.  W.  White,  M.D. :  A  Contribution  to  the  History  of 
Influenza;  being  a  Study  of  a  Series  of  Cases.  Philadelphia  Medical  Times,  April 
10,  1880. 

'  Clinical  Medicine. 


26  THE    CONTINUED    FEVERS. 

Some  writers  have  thought  that  an  attack  of  influenza  may  degene- 
rate into  intermittent  fever.  It  is  more  probable,  that  the  instances 
observed  were  endemics  of  intermittents,  making  their  appearance  upon 
the  subsidence  of  epidemics  of  influenza. 

The  facts  in  reference  to  the  spread  of  epidemics  of  influenza  and 
the  course  of  the  disease  in  infected  localities,  are  comprehensible  upon 
no  other  theory  than  that  of  a  specific  principle  of  disease  as  its  exciting 
cause.  What  this  principle  may  be,  is  not  yet  known  to  us  ;  where  it 
originates  is  equally  unknown,  and  our  knowledge  of  the  influences  that 
from  time  to  time  call  it  into  activity,  and  send  it  forth  in  definite  direc- 
tions over  the  earth,  is  no  less  negative. 

So  general  a  disease  can  only  be  disseminated  by  the  most  general 
medium,  the  atmosphere,  and  its  exciting  cause  must  be  capable  of  repro- 
ducing itself  in  that  medium;  otherwise  it  would  be  lost  by  dispersion  in 
traversing  distances  measured  by  the  boundaries  of  continents  and  oceans. 
The  rapid  diffusion  of  influenza,  sweeping  over  continents  in  a  few  weeks 
at  one  time;  its  slow  migration,  creeping  about  a  city  and  its  environs 
for  months  at  another,  are,  as  Biermer  ^  suggests,  to  be  most  easily  ex- 
plained upon  the  theory  of  a  living  miasm,  capable  of  being  transmitted 
by  the  air,  and  possessing  at  the  same  time  an  independent  existence. 
Such  an  entity  would  find  certain  localities  more  favorable  to  its  growth, 
reproduction,  and  prolonged  existence,  than  others.  From  this  point  of 
view  influenza  is  a  miasmatic  disease. 

From  a  fair  consideration  of  what  has  been  written  concerning  its 
local  dissemination,  it  must  be  admitted  that  its  causes  are,  to  a  slight  ex- 
tent, capable  of  being  reproduced  in  or  about  the  human  body,  and  trans- 
mitted by  personal  intercourse,  as  well  as  conveyed  from  place  to  place 
by  the  persons  or  clothing  of  those  affected,  or  travelling  from  localities 
in  which  the  disease  prevails. 

We  are  thus  led  to  the  conclusion  that  it  is  also  contagious,  though 
feebly  so. 

Influenza,  in  view  of  these  theories  of  its  exciting  causes,  may  be  de- 
scribed as  a  miasmatic-contaffious  fever. 


Clinical  Histoby. 

The  course  of  the  disease,  in  individual  cases,  presents  the  greatest 
variations  as  regards  intensity,  from  the  most  trifling  indisposition  to  an 
illness  of  the  gravest  kind,  terminating  in  death. 

These  variations  are  dependent  upon:  1st,  the  previous  health  of  the  in- 
dividual, his  age,  and  the  power  of  resisting  depressing  influences  which  he 

'  Biermer  :  Virchow's  Handbuch  der  speciel.  Pathologie  u.  Therapie.  Band  V.  Ite 
Abth.  4tc  LiefcruDg.     Erlangen,  1805.  s 


I 


I 


INFLUENZA.  27 

possesses;  2d,  the  energy  and  the  amount  of  the  specific  cause  of  the  dis- 
ease to  which  he  has  been  exposed — in  other  words,  the  dose  of  the  fever- 
producing  poison;  and  3d,  the  character  of  the  prevailing  epidemic. 

It  is,  however,  important  to  observe  that,  as  has  already  been  stated, 
cases  of  very  great  severity  are  occasionally  encountered  during  the  preva- 
lence of  mild  epidemics. 

In  every  epidemic,  on  the  contrary,  a  considerable  part  of  the  commu- 
nity suffers  from  influenza  in  the  mildest,  or  what  has  been  called  the 
"  rudimentary  "  form.  This  is  characterized  by  general  "  malaise,"  an 
easily  oncoming  weariness  of  bodily  and  mental  effort,  a  disinclination  for 
business,  some  inability  to  fix  the  attention,  and  slight  mental  confusion; 
to  these  nervous  disturbances  are  added  slight  catarrhal  symptoms,  as 
coryza,  sore  throat,  a  tickling  cough,  and  the  like;  but  the  indisposition  is 
subfebrile — it  does  not  amount  to  a  fully  developed  fever. 

Another  portion  of  the  cases  in  most  epidemics  present  the  symptoms 
of  an  ordinary  attack  of  acute  coryza,  laryngitis,  bronchitis,  pharyngitis, 
with  great  increase  in  the  constitutional  disturbances,  distresuing  head- 
ache, and  pains  in  the  back  and  limbs.  The  fever  in  this  class  of  cases 
does  not  range  high,  yet  the  patients  are  ill  enough  to  betake  themselves 
to  bed. 

The  onset  of  the  attack  in  severe  cases  is  usually  abrupt.  It  begins 
with  shivering  or  a  chill,  or  with  fits  of  chilliness  alternating  with  heat. 
Fever  is  rapidly  established.  It  is  usually  moderate,  though  it  sometimes 
reaches  a  high  grade.  It  shows  a  tendency  to  morning  remissions.  Sen- 
sations of  chilliness  are  apt  to  occur;  they  are  called  forth  by  even  slight 
changes  in  the  external  temperature.  These  chilly  sensations  are  apt  to 
be  followed  during  the  course  of  the  fever  by  the  sensation  of  flushes  of 
heat,  and  are,  in  many  cases,  attended  by  annoying  sweats. 

The  febrile  outbreak  is  sometimes  preceded  for  a  little  time  by  intense 
frontal  headache,  with  pain  in  the  orbits  and  at  the  root  of  the  nose.  In 
other  cases  these  pains  quickly  follow  the  chill.  Sneezing,  redness  of  the 
eyes  and  edges  of  the  nostrils,  a  more  or  less  abundant  thin  discharge  from 
the  nose,  and  lachrymation,  now  occur.  In  some  instances  there  is  bleed- 
ing from  the  nose.  The  throat  becomes  sore,  there  is  a  tickling  sensation 
in  the  upper  air-passages,  a  dry  cough  sets  in,  attended  by  more  or  less 
hoarseness  and  shortness  of  breath.  The  cough  is  paroxysmal,  hard,  dis- 
tressing. It  sometimes  causes  vomiting,  like  that  which  occurs  in  the 
paroxysms  of  whooping-cough.  Chest-pains,  stitches  in  the  side  (not 
pleuritic),  frequent  sneezing,  loss  of  the  sense  of  smell  and  of  taste,  attend 
the  development  of  the  general  catarrhal  manifestations. 

The  fever  is  attended  by  great  depression,  pains  in  the  limbs,  loss  of 
appetite,  thirst,  constipation,  and  diminished  secretion  of  urine.  The 
pulse  is  full,  but,  as  a  rule,  only  moderately  increased  in  frequency.  There 
is  in  many  cases  slight,  or  even  decided  blueness  of  the  lips  and  finger- 


28  THE    CONTINUED    FEVERS. 

tips.  The  patient  is  distressed  by  restlessness  and  want  of  sleep.  At 
the  end  of  four  or  five  days  the  febrile  symptoms  decline,  at  times  gradu- 
ally, oftener  rapidly,  with  copious  sweats  or  spontaneous  flux  from  the 
bowels.  The  fever  continues,  however,  when  severe  complications  have 
taken  place  ten  or  twelve  days.  The  defervescence  is  marked  by  an  in- 
creased flow  of  sedimentary  urine,  and  considerable  amelioration  of  the 
subjective  symptoms.  The  catarrhal  symptoms  outlast  the  fever  two  or 
three  days,  but  cough  and  expectoration  may  not  disappear  for  some 
time. 

Attendant  upon  these  symptoms  and  proportionate  to  the  severity  of 
the  fever  or  the  catarrh,  or  both,  that  is  to  say,  in  proportion  to  the  grav- 
ity of  the  attack  in  general,  are  the  evidences  of  functional  disturbance 
of  the  nervous  system.  There  is  remarkable  nervous  depression,  loss  of 
strength  and  lowness  of  spirits,  combined  with  mental  weakness,  and  even 
stupor  and  delirium.  In  some  cases  slight  convulsions  take  place.  Cu- 
taneous hvperassthesia  occasionally  occurs,  and  Da  Costa  states  that  areas 
of  burning  pain  in  the  skin  are  to  be  met  with.  Neuralgia,  muscle-pain, 
and  aching  referred  to  the  bones,  are  very  common  and  often  severe. 

In  other  cases  abdominal  symptoms  are  prominent,  while  those  refer- 
able to  the  head  and  chest  are  less  urgent.  The  disease  assumes  the 
guise  of  a  more  or  less  severe  catarrh  of  the  gastro-enteric  mucous  mem- 
brane, with  hepatic  disturbance.  The  fever  and  the  peculiar  nervous  de- 
pression, spoken  of  in  the  foregoing  account  of  the  course  of  the  affection, 
are  the  same.  Cases  likewise  present  themselves,  but  less  commonly,  in 
which  but  little  of  the  usual  tendency  to  localization  of  the  catarrhal  pro- 
cesses is  to  be  observed;  there  is  fever  of  varying  intensity,  with  great 
depression,  and  simultaneous  and  equal  implication  of  the  head  and  the 
organs  of  the  chest  and  abdomen. 

Many  writers  have  sought  to  arrange  the  foregoing  different  forms  of 
influenza  in  definite  categories.  It  would  be  a  useless  task  to  reproduce 
their  views  upon  the  subject,  or  even  to  enumerate  the  varieties  that 
they  have  described.  In  truth,  it  is  open  to  doubt  whether  it  would  serve 
any  useful  didactic  purpose  to  do  so,  while  in  practice  the  various  de- 
scribed types  merge  so  gradually  into  each  other,  and  are  so  modified  by 
the  individual  peculiarities  of  the  sick,  and  by  the  complications  which 
arise  in  the  course  of  the  attack  in  consequence  of  such  peculiarities  or  of 
previously  existing  diseases  or  tendencies  to  special  forms  of  disease,  that 
particular  cases  cannot  in  most  instances  be  referred  to  theoretical  cate- 
gories. In  illustration  of  this  remark,  it  is  to  be  stated  that  h\'sterical 
persons  and  those  of  what  we  may  term  a  nervous  constitution,  are  prone 
to  suffer  especially  from  the  peculiar  nervous  symptoms  of  influenza.  So 
also  the  disease  is  modified  by  the  age  of  the  subject  of  the  attack,  and 
children  manifest,  in  a  high  degree,  the  signs  of  cerebral  congestion,  while 
old  persons  are  subject  in  a  peculiar  manner  to  dangerous  pulmonary 


INFLUENZA.  29 

complications,  and  those  of  a  gouty  or  rheumatic  constitution  suffer  from 
muscular  pains  more  than  others. 

The  duration  of  the  mildest  form  of  influenza  is  from  two  to  three 
days;  in  well-developed  cases  without  complications,  convalescence  sets 
in  between  the  fourth  and  tenth  days,  and  severe  cases  with  complications 
may  last  much  longer — several  weeks  elapsing  before  recovery  is  com- 
plete. 

Analysis  of  the  Symptoms. 

For  the  purpose  of  separate  consideration,  it  will  be  found  convenient 
to  take  up  the  symptoms  belonging  to  the  fever  first,  then  those  of  the 
special  catarrh,  and  finally  those  more  particularly  referable  to  the  ner- 
vous system;  but  we  encounter,  in  the  present  state  of  our  knowledge  of 
the  pathology  of  influenza — or  it  would  be  perhaps  better  to  say,  our  igno- 
rance of  its  pathology — no  little  difficulty  in  deciding  under  which  of  these 
headings  particular  symptoms  are  properly  to  be  classed,  by  reason  of  the 
close  interdependence  of  the  chief  processes  of  the  disease  and  the  anoma- 
lies of  its  phenomena  viewed  as  a  whole. 


THE  FEVER. 

Temperature. — The  older  observers  concluded,  from  the  diminished 
frequency  of  the  pulse  by  day  as  compared  with  that  of  the  night,  the  less 
urgent  subjective  symptoms  and  the  relatively  cooler  skin,  that  the  type 
of  the  fever  was  remittent  or  subcontinuous.  This  is  doubtless  the 
case,  although  accurate  thermometric  observations,  by  which  alone  the 
type  of  any  fever  can  be  with  certainty  established,  are  as  yet,  even  in 
the  most  recent  epidemics,  wanting  in  sufficient  numbers  to  enable  us  to 
formulate  any  law. 

The  intensity  of  the  fever-process  is  variable.  As  a  rule  it  is  mode- 
rate or  slight  ;  occasionally  it  is  intense.  I  observed,  in  several  cases 
during  the  epidemic  of  1879  in  Philadelphia,  an  evening  temperature  of 
only  39°  C.  (102.2°  F.).  Da  Costa,  in  the  same  outbreak,  found  the  febrile 
movement  not  high  ;  the  highest  temperature  he  observed  was  40°  C. 
(104°  F.).  Biermer  found  a  temperature  of  over  39°  C.  in  moderate 
cases  of  catarrhal  fever,  and  does  not  doubt  that  under  certain  transient 
conditions  the  temperature  may  reach  the  height  of  that  of  pneumonia 
or  typhus.     In  weakly  persons  and  the  aged,  the  fever  is  adynamic. 

The  circidation. — The  pulse  is  variable.  Its  frequency  is  moderately 
increased  ;  it  is  sometimes  full,  sometimes  weak.  It  has  no  constant 
character.  Some  observers  have  noted  a  frequent  irregularity.  Graves 
informs  us  that  in  many  cases  the  condition  of  the  pulse  was  very  change- 


30  THE    CONTINUED    FEVERS. 

able,  and  that  it  often  became  quite  dilTerent  in  character  in  the  course  of 
a  few  hours. 

The  secretions. — The  urine  is  usually  diminished,  sometimes  its  secre- 
tion is  temporarily  suppressed.  It  often  shows  but  little  change,  but  is 
more  commonly,  as  in  other  fevers,  concentrated  and  high-colored.  It 
deposits,  on  cooling,  a  sediment  of  urates,  which  toward  the  close  of  the 
fever  is  often  very  abundant.  The  defervescence  is  in  many  instances 
attended  by  a  copious  secretion  of  urine.  Exact  observations  as  to  the 
composition  of  the  urine  in  twenty-four  hours  are  wanting. 

At  first  the  skin  is  hot  and  dry  ;  sometimes  frequent  sweats  occur, 
free  sweating  generally  marks  the  febrile  remissions,  and  the  deferves- 
cence not  rarely  sets  in  with  copious,  acid,  ill-smelling  sweats.  In  some 
cases  the  tendency  to  sweat  shows  itself  early  and  continues  throughout 
the  attack.  Sudamina  occur  in  great  numbers.  An  outbreak  of  herpes 
about  the  lips  is  occasionally  seen. 

The  digestive  system. — Disturbances  of  the  digestive  tract  are  more 
or  less  prominent  in  almost  all  cases.  Only  in  the  rudimentary  and  sub- 
febrile  forms,  and  even  then  most  rarely,  are  they  absent.  In  many  cases 
they  are  such  as  are  usually  seen  in  febrile  disorders,  namely,  loss  of  ap- 
petite, thirst,  impaired  taste,  pasty,  coated  tongue,  tenderness  in  the  epi- 
gastrium, and  constipation.  Nausea  and  vomiting  sometimes  usher  in  the 
attack.  In  other  cases  (the  so-called  abdominal  form)  all  the  above  symp- 
toms are  more  severe,  and  diarrhoea,  colicky  pains  and  vomiting  are 
superadded. 

TJie  countenance  is  changed,  in  part  by  the  appearance,  characterizing 
an  ordinary  attack  of  coryza,  of  considerable  or  great  severity,  and  in 
part  by  an  expression  of  anxiety  and  depression.  It  is  pale.  Where  the 
pulmonary  catarrh  is  excessive  and  the  dyspnoea  great,  the  lips  become 
bluish.     The  facies  sometimes  suggests  that  of  typhoid  fever. 


THE  CATAKEH, 

A  more  or  less  extensive  hyperajmia  of  the  mucous  membrane  of  the 
respiratory  tract  is  invariably  present,  and  may  be  said  to  characterize  the 
disease.     The  symptoms  are  essentially  of  a  catarrhal  nature. 

There  is  cold  in  the  head,  more  severe  in  most  cases  than  ordinary 
simple  coryza.  The  eyelids  are  swollen  and  reddened,  there  is  abundant 
lachrymation,  sneezing  is  frequent,  and  the  discharge  fi'om  the  nose  is 
abundant.  Epistaxis  is  not  rare.  Sore  throat,  with  tickling  sensations 
and  difliculty  in  swallowing,  are  due  to  inflammation  of  the  pharynx  and 
neighboring  parts.  In  many  instances  the  catarrhal  symptoms  are  refer- 
able to  a  pharyngitis  and  tonsillitis  only,  the  lower  air-passages  escaping. 
Hoarseness  is  common. 


INFLUENZA.  31 

Tlie  cough. — This  has  been  in  most  epidemics  a  prominent  symptom. 
It  is  apt  to  be  frequent  and  distressing — sometimes  paroxysmal  from  the 
beginning  of  the  sickness,  almost  always  so  during  its  course.  Its  spas- 
modic character  in  some  of  the  older  epidemics  led  to  the  confounding  of 
epidemic  catarrhal  fever  with  whooping-cough.  It  is  apt  to  be  worse  to- 
ward evening  and  at  night,  but  the  sick  are  often  tormented  day  and  night 
by  the  racking,  loud  cough.  It  often  leads  to  vomiting,  and,  by  its  vio- 
lence and  persistence,  gives  rise  to  pain  and  soreness  in  the  muscles  of 
respiration  (myalgia),  and  occasionally  to  hernia.  It  is  at  first  dry,  or 
attended  with  a  scanty  muco-serous  expectoration;  later  on,  the  sputa 
become  opaque  and  muco-purulent,  and  in  consumptive  or  full-blooded 
persons,  or  those  having  mitral  disease,  they  are  sometimes  streaked  or 
mingled  with  blood.  Toward  the  close  of  the  attack  the  cough  becomes 
less  urgent  and  loses  its  spasmodic  character.  In  some  epidemics  cough 
is  not  a  prominent  symptom,  and  a  few  cases  are  encountered  in  most 
epidemics  in  which  well-developed  influenza  runs  its  course  without  unu- 
sual, peculiar,  or  excessive  cough.  If  the  cough  be  due  to  bronchitis,  we 
find  on  auscultation  the  physical  signs  of  that  affection.  They  are  of 
course  wanting  when  it  is  due  simply  to  laryngo-tracheal  irritation. 
Hence,  we  frequently  detect  sonorous  and  sibillant,  or  mucous  and  subcre- 
pitant  rales  upon  both  sides  of  the  chest  in  the  course  of  the  attack,  as  in 
non-epidemic  acute  bronchitis  ;  and,  on  the  other  hand,  cases  occur 
where  the  auscultatory  signs  are  but  little,  or  not  at  all,  altered  from  those 
of  health.  It  is  scarcely  necessary  to  add  there  are  no  special  character- 
izing signs  that  can  be  regarded  as  diagnostic  of  influenza. 

Dyspnoea. — Many  patients  suffer  from  this  symptom.  It  is  due,  in 
some  instances,  to  complications;  but  it  also  occurs  with  remarkable  fre- 
quency in  those  in  whom  none  of  the  objective  signs  of  any  lesions  can 
be  discovered  in  the  lungs.  It  is  here  of  nervous  origin.  Graves  assumes 
a  direct  disturbance  in  the  function  of  the  vagus  as  its  cause.  This  view 
is  sustained  by  the  observation  that  the  dyspnoea  is  now  and  then  inter- 
mittent, or  shows  rhythmically  recurring  remissions,  which  are  unattended 
by  alteration  of  the  physical  signs.  To  Biermer  it  appears  more  probable 
that  the  congestions  so  common  in  influenza,  not  attended  by  marked 
physical  signs  until  they  lead  to  oedema,  are  to  be  regarded  as  the  cause 
of  the  dyspnoea. 

It  varies  greatly  in  intensity.  In  many  patients  it  goes  on  to  marked 
oppression,  great  shortness  of  breath,  precordial  pain,  and  the  like.  In 
certain  epidemics,  orthopnoea  and  suffocative  attacks  were  very  common. 

Stitches  in  the  side,  and  pain  under  the  sternum,  are  observed  without 
appreciable  physical  signs. 


32  THE    CONTINUED    FEVERS. 


I 


SYMPTOMS  BEFERAELE  TO  THE  NEBVOUS  SYSTEM. 


Debility. — Great  prostration  of  muscular  strength  is  a  very  early 
symptom,  and  constitutes,  in  most  epidemics,  one  of  the  remarkable  fea- 
tures of  the  disease.  Patients  from  the  onset  feel  extremely  weak,  and 
are  exhausted  by  the  slightest  bodily  effort.  The  ordinary  strength  is 
not  regained  until  convalescence  is  far  advanced. 

Headache. — Severe  frontal  pains  are  scarcely  ever  absent,  Thev  ex- 
tend across  the  brow,  and  deeply  about  the  orbits  and  at  the  root  of  the 
nose,  having  their  seat  in  the  Schneiderian  mucous  membrane  and  its 
prolongations  lining  the  frontal  sinuses  and  the  nasal  ducts.  Sometimes 
the  pain  is  referred  also  to  the  region  of  the  antrum  of  Highmore,  and  to 
the  Eustachian  tube  and  the  middle  ear.  It  occasionally  extends  over  the 
whole  head.  Cutaneous  hyperesthesia  of  the  head  and  neck,  and  stiffness 
of  the  neck-muscles,  are  also  met  with.  The  headache  is  often  most  in- 
tense ;  it  lasts  commonly  till  the  end  of  the  attack,  and  may  even  outlast 
it.  It  increases  in  severity  toward  evening,  with  the  fever  and  mental 
agitation.     The  occurrence  of  epistaxis  affords  some  relief. 

Pain. — Among  the  more  constant  symptoms  of  influenza  are  very  se- 
vere pains  in  the  limbs.  Patients  experience  sensations  of  soreness  and 
bruising,  such  as  follow  the  most  severe  and  unaccustomed  muscular  ef- 
fort. Dull,  tearing,  and  burning  pains  are  felt  sometimes  in  particular 
muscles  or  tendons  ;  sometimes  they  are  diffused  over  the  whole  bodv. 
Distressing  pains  of  a  dragging  or  boring  character,  in  the  loins  and  the 
calves  of  the  legs,  are  complained  of.  These  pains  are  neither  relieved 
nor  aggravated  by  gentle  movement  or  by  moderate  pressure.  A  sense 
of  contraction  of  the  chest,  and  precordial  distress  also  occur  and  stitches 
in  the  side  (pleurodynia),  substernal  pain,  and  pains  in  the  throat  and  nape 
of  the  neck,  are  common. 

General  nervous  symptoms. — Patients,  when  the  case  is  severe,  are 
usually  restless,  sleepless,  and  anxious.  Dizziness  and  a  tendency  to  faint 
occur  on  rising,  particularly  in  women.  Mild  delirium  is  not  uncommon  ; 
bnt  the  more  intense  forms  are  also  observed.  Active  delirium  was 
thought  to  be  a  mortal  symptom  in  some  of  the  older  epidemics. 

The  inability  to  sleep  bears  no  direct  relation  to  the  intensity  of  the 
fever.     It  is  seen  in  some  cases  where  fever  is  slight  or  even  absent. 

Somnolent  states  also  occur.  Great  hebetude  and  torpor  have  marked 
some  epidemics.  That  of  1712  was  called  the  sleepy  sickness,  by  reason 
of  the  prevalence  of  these  symptoms. 

In  the  gravest  cases,  painful  muscle-cramps,  subsultus  tendinum, 
twitchings  of  particular  muscles,  and  tremblings  of  the  hands,  are  observed. 

The  mental  power  is  enfeebled,  and  the  acuteness  of  the  special  senses 
is  diminished. 


INFLUENZA.  33 


Complications  and  Sequels. 

The  most  important  complications  of  influenza  are  inflammatory  dis- 
eases of  the  lungs.  The  intense  hyperaemia  and  bronchitis,  already  de- 
scribed as  occurring  in  the  severer  cases,  cannot  properly  be  looked  upon 
as  complications.  They  constitute  rather  essential  processes  of  particular 
forms  of  the  disease.  But  capillary  bronchitis,  catarrhal  pneumonia,  and, 
less  frequently,  croupous  pneumonia,  arise  as  complications  in  the  course 
of  the  disease.  Pleurisy,  except  as  associated  with  lobar  pneumonia,  is 
rarely  met  with.  Satisfactory  statistics  are  wanting,  but  Biermer  estimates 
that  from  five  to  ten  per  cent,  of  the  whole  number  of  patients  suffer  from 
inflammatory  lung-complications,  and  holds  that  the  bloodletting  so  fre- 
quently practised  by  the  older  physicians  was  due  to  a  desire  to  combat 
iiiflammation.  The  comparative  frequency  of  chest-complications  in  dif- 
ferent epidemics  varies  greatly,  but  the  estimate  of  Biermer  may  be  ac- 
cepted as  an  approximate  average. 

Owing  to  the  masking  of  the  physical  signs  in  the  early  stages,  and 
the  pre-existing  pulmonary  oedema,  it  is  not  always  easy  to  recognize  at 
once  the  occurrence  of  capillary  bronchitis.  It  is  attended  with  increasing 
dyspnoea,  decided  lividity  of  the  face  and  extremities,  and  greater  pros- 
tration. Crepitant  and  sub-crepitant  rales  at  the  lower  portions  of  the 
posterior  dorsal  regions,  rapidly  spreading  over  all  parts  of  the  chest, 
without  dulness  at  first  and  with  increased  resonance  later,  instead  of  the 
signs  of  condensation  which  are  met  with  in  pneumonia,  are  the  signs 
which  attend  its  appearance. 

Catarrhal  pneumonia  occurs  insidiously,  with  gradual  intensification  of 
the  bronchitic  symptoms  about  the  fourth  or  fifth  day;  but  it  may  set  in 
as  early  as  the  second  day,  or  much  later,  during  convalescence.  It  is 
developed  without  chill,  as  a  rule,  or  great  increase  in  the  fever.  Old  per- 
sons and  those  of  feeble  constitutions  are  more  liable  to  the  foregoing 
complications.  Lobar  pneumonia  is  less  common.  It  is  a  late  complica- 
tion, occurring  toward  the  close  of  the  attack,  or  even  when  the  patient 
is  beginning  to  get  about.  It  is  easily  recognized,  and  differs  in  no  wise 
from  acute  lobar  pneumonia  occurring  under  other  circumstances. 

In  October,  1880,  influenza  being  in  Philadelphia,  both  epizootic  and 
epidemic,  but  very  mild  among  both  horses  and  men,  I  attended  a  medi- 
cal student,  who,  having  had  what  he  regarded  as  a  "  cold  "  for  about  a 
week,  had  kept  at  his  work  without  treatment,  until,  upon  the  occurrence 
of  a  chill  followed  by  grave  thoracic  symptoms,  he  was  obliged  to  betake 
himself  to  bed.  I  first  saw  him  the  following  day,  in  the  Hospital  of  th« 
Jefferson  College.  There  were  the  symptoms  of  acute  lobar  pneumonia, 
with  the  signs  of  extensive  consolidation  of  the  left  lung  and  pleurisy  of 
the  right  side.  Moreover  delirium  and  jaundice  were  present.  The  urine 
3 


34  THE   CONTINUED    FEVERS. 

was  non-albuminous.  The  next  evening  lie  died.  At  the  same  time  many 
members  of  the  class  suffered  from  unquestionable  influenza,  and  a  careful 
inquiry  into  the  history  of  the  case  of  this  young  gentleman  satisfied  me 
that  the  pneumonia  had  arisen  as  a  complication  of  a  neglected  and  mod 
erately  severe  catarrhal  fever.  Until  the  eighth  day  before  his  death  he 
was  in  excellent  health.     No  examination  of  the  body  was  permitted. 

Graves  '  thought  that  a  kind  of  paralysis  of  the  lungs,  with  great  cedema, 
takes  place  in  some  cases,  and  attributed  it  to  an  affection  of  the  vagus. 
It  was  his  conviction  "that  the  poison  which  produced  influenza  acted  on 
the  nervous  system  in  general,  and  on  the  pulmonary  nerves  in  particular, 
in  such  away  as  to  produce  symptoms  of  bronchial  irritation  and  dyspnoea, 
to  which  bronchial  congestion  and  inflammation  were  often  superadded." 

It  is  certain  that  localized  collapse  of  the  lung  often  occurs.  Drs. 
White  and  Guiteras  attributed  the  consolidations  of  the  lung  to  congestive 
collapse  due  to  enlargement  of  the  tracheal  and  bronchial  glands,  and 
"  disturbance  of  the  great  nervous  tract  about  the  root  of  the  lung." 
They  were  enabled  to  satisfy  themselves  of  the  existence  of  the  glandular 
enlargement — admopathie  bronchique — in  nine  of  their  eighteen  cases, 
by  percussion  practised  in  the  method  of  M.  Geneau  de  Mussy,^  who  was, 
as  they  believe,  the  first  to  call  attention  to  the  information  that  may  be 
gained  by  percussion  of  the  spinous  processes  of  the  vertebrae  over  the 
course  of  the  trachea.  Following  this  line  in  the  healthy  subject,  a  dis- 
tinct tubular  (high-pitched  and  slightly  tympanitic)  sound  is  elicited  by 
percussion,  down  to  the  point  of  bifurcation  of  the  trachea,  on  the  level 
of  the  fourth  dorsal  vertebra.  Opposite  the  fifth,  and  downward,  we  get 
the  lower-pitched  pulmonary  resonance.  When  the  tracheal  and  bron- 
chial glands  are  enlarged,  the  tubular  sound  over  the  upper  dorsal  vertebrae 
is  replaced  by  dulness,  which  may  contrast  sharply,  above  with  the  tracheal,  , 
and  below  with  the  vesicular  resonance. 

They  point  out  some  well-recognized  peculiarities  of  the  so-called  i 
pneumonias  of  influenza,  as  giving  weight  to  their  view  that  the  consoli- 
dations are  not,  in  the  beginning,  pneumonia  at  all.  Thus,  we  have  at 
first  weakness  of  the  vesicular  murmur,  then  its  absence;  the  respiration 
soon  becomes  bronchial  without  being  preceded  by  dulness  or  the  crepi- 
tant rale;  the  extension  of  these  consolidations  from  one  part  of  the  lung 
to  another  is  very  irregular;  the  process  is  more  apt  to  involve  both  sides 
than  one;  the  disappearance  of  the  consolidation  is  frequently  very  rapid. 

The  physical  signs  in  one  of  their  patients  were  very  interesting,  as 
supporting  the  theory  of  collapse  from  the  nerve-disturbance  consequent 
upon  enlargement  of  the  lymphatic  glands.  The  case  presented,  one  day, 
pectoriloquy  and  bronchial  breathing  at  the  root  of  the  left  lung;  the  next 
day  there  was  dulness  of  a  large  portion  of  the  left  lower  lobe,  with  bron- 

'  Annals  of  Influenza.  ^  Clinique  Medicale.     Paris,  1874. 


INFLUENZA.  35 

chophony  and  bronchial  breathing  over  an  area  extending  from  above  the 
angle  of  the  scapula  to  the  base,  and  out  to  the  axillary  line.  That  is  to 
sav,  there  was,  first,  engorgement  of  the  left  bronchial  glands,  and  the 
next  day  the  congestive  collapse  of  portions  of  the  lung.  On  the  day 
after  this,  no  traces  could  be  found  of  the  consolidation.  This  is  certainly 
not  the  history  of  catarrhal  pneumonia. 

The  relations  of  cause  and  effect  between  collapse  and  catarrhal  pneu- 
monia are  so  close,  that  it  is  not  diflBcult  to  see  how  the  condition  spoken 
of  may  lead  to  secondary  lobular  or  catarrhal  pneumonia.  In  truth,  this 
is  a  frequent  result  of  collapse  from  any  cause. 

They  do  not  adduce  any  post-mortem  facts  in  support  of  their  theory. 
Peacock,'  however,  observed  in  the  epidemic  of  1847,  softening  and  en- 
lar<rement  of  the  bronchial  glands  in  several  cases,  and  in  one  instance 
where  there  was  no  antecedent  disease  of  the  lungs,  and  where  the  physi- 
cal signs  corresponded  to  some  extent  with  those  of  the  cases  upon  which 
Drs.  White  and  Guiteras  base  their  views.  These  complications  are  the 
chief  cause  of  the  danger  of  influenza  in  the  aged,  the  debilitated,  and 
those  suffering  from  previous  disease  of  the  thoracic  organs. 

Pleurisy  is  rare,  except  where  there  is  coexisting  inflammation  of  the 
lungs.  It  may  be  associated  with  pericarditis.  In  old  persons,  serous 
effusions  into  the  pleural  sac  are  now  and  then  encountered. 

Troublesome  laryngitis  and  chronic  bronchitis  may  follow  the  attack. 
In  consequence  of  the  extension  of  the  catarrhal  processes  along  the 
Eustachian  tube,  an  actual  inflammation  of  the  middle  ear  is,  in  rare  in- 
stances, set  up.  Parotitis  with  salivation  sometimes  occurs,  likewise 
aphthous  inflammations  of  the  mouth. 

Herpes  labialis  may  occur  as  a  favorable  indication. 

Latent  phthisis  may  be  developed  by  an  attack  of  influenza,  and  if 
phthisis  be  already  established  it  may  run  a  more  rapid  course.  Emphy- 
sematous affections  are  aggravated;  diseases  of  the  heart  are  unfavorably 
influenced  ;  nervous  affections  may  be  made  worse,  and,  in  particular, 
neuralgias  are  aggravated.  Old  neuralgias,  that  have  long  ceased  to  give 
trouble,  have  been  known  to  reappear  during  the  convalescence  from  in- 
fluenza. 

Many  of  the  older  observers  have  recorded  the  intermittent  character 
of  influenza  in  certain  epidemics,  and  its  tendency  to  run  into  intermit- 
tents,  particularly  of  a  tertian  type,  during  convalescence.  This  has 'not 
been  observed  in  the  outbreaks  of  later  years,  and  it  is  probable  that  in 
such  instances  an  endemic  malaria  has  modified  the  epidemic  catarrhal 
fever,  or  the  former  has  broken  out  as  the  latter  passed  away. 

Pregnant  women  are  in  danger  of  aborting. 

Women  who  have  suffered  from  amenorrhoea  have  had  the  menses 

'Loc.  cit. 


36  THE    CONTINUED    FEVERS. 

re-established  after  an  attack  of  influenza.    This  statement  has  been  veri- 
fied repeatedly  in  several  epidemics. 


Pathology. 

From  the  absence  of  sufficient  pathological  investigation,  our  knowl- 
edge of  influenza  is  as  yet  very  incomplete.  Biermer  has  described  it 
as  the  sum  of  a  series  of  catarrhal  manifestations  which  have  developed 
under  common  epidemic  influences.  The  close  association  of  the  various 
local  affections  arises  from  their  almost  simultaneous  occurrence  in  con- 
siderable numbers,  and  the  identity  of  the  primary  pathological  processes 
which  underlie  them.  As  regards  mucous  surfaces,  these  lesions  consist 
principally  in  hyperaemia.  The  nature  of  the  lesion  underlying  the  ner- 
vous phenomena  is  altogether  unknown.  Nevertheless,  it  may  be  assumed 
that  the  causation  of  both  the  catarrhal  and  the  nervous  symptoms  is 
essentially  the  same  ;  while  the  relation  of  both  to  the  fever,  forces  us  to 
the  conclusion  that  it  is  also  a  separate  result  of  the  same  cause,  since  no 
constant  relation  either  as  to  time  or  intensity  exists  among  the  three 
groups  of  symptoms  in  question,  although  they  appear  in  a  general  way 
nearly  simultaneously.  That  is  to  say,  headache,  weakness,  malaise,  may 
precede  the  fever,  with  coryza  and  the  like,  or  the  coryza  may  precede 
the  fever,  or  even  occur  without  marked  fever,  in  which  case  more  or  less 
fully  developed  nervous  phenomena  are  never  absent;  or,  as  is  more  fre- 
quently the  case,  the  chill  or  chilliness  which  forms  part  of  the  fever  and 
ushers  it  in,  is  the  first  sudden  manifestation  of  the  disease.  At  the  same 
time  the  nervous  symptoms  are  in  some  cases  marked,  with  very  moderate 
coryza,  bronchitis  and  so  on,  or  a  considerable  febrile  movement  may  be 
attended  with  comparatively  mild  catarrhal  symptoms,  and  a  degree  of 
nervous  perturbation  that  is  relatively  slight.  In  severe  cases,  the  catarrhal 
and  the  nervous  symptoms  are  apt  to  be  severe,  while  the  febrile  move- 
ment may  be  in  correspondence  with  them,  or  may  be  of  only  moderate 
energy. 

These  facts  point  to  a  common  cause  for  the  varied  phenomena  of  in- 
fluenza, and  it  may  be  confidently  asserted  that  each  of  the  three  groups 
of  symptoms  constitutes  a  distinct  factor  of  the  disease.  This  view  is  at 
variance  with  the  opinion — based  upon  the  fact  that  acute  common  catarrh, 
bronchitis,  tonsillitis,  and  other  acute  affections,  sometimes  run  their, 
course  in  a  similar  way  to  influenza,  with  fever,  nervous  depression,  and  a; 
serious  sense  of  illness — that  influenza  is  in  essence  simply  an  epidemic! 
catarrh.  Moreover,  the  sudden  onset  of  influenza,  its  not  infrequent 
abrupt  termination — which  suggests  crisis — its  unsparing  seizure  of  great 
numbers  of  the  population,  the  severity  of  the  nervous  symptoms,  and 
the  amount  of  laryngo-bronchial  irritation — often  out  of  measure  with 


INFLUENZA.  37 

the  lesions  of  the  mucous  membrane, — all  point  to  the  action  of  a  morbid 
agent  affecting  the  body  at  large.  The  severity  of  the  symptoms  also,  in 
many  cases,  is  much  greater  than  in  acute  non-specific  local  affections, 
■while  the  complications,  and  in  particular  the  recrudescence  of  fading 
neuralgias  and  the  tendency  to  abortion,  and  the  sequels,  as  cough, 
weakness,  headaches,  flying  pains,  which  often  remain  long  after  con- 
valescence, are  evidences  of  its  belonging  to  the  group  of  infectious  dis- 
eases rather  than  to  that  of  simple  acute  inflammatory  diseases. 

In  conclusion,  it  must  be  urged  that  the  similarity  of  the  symptoms  in 
many  epidemics,  occurring  during  the  course  of  several  centuries  and 
under  different  social  conditions  and  even  different  degrees  of  civilization, 
forcibly  demonstrates  the  specific  and  definite  character  of  the  causes 
■which  give  rise  to  influenza. 

Morbid  anatomy. — Very  little  light  is  thrown  upon  the  pathology  of 
the  disease  by  the  anatomical  changes  found  after  death.  Uncomplica- 
ted influenza  is  rarely  fatal.  As  a  rule,  it  is  found  that  the  unfavorable 
termination  is  in  consequence  of  lung  complications.  The  essential  le- 
sions are  congestion  and  catarrhal  swelling  of  the  mucous  membrane  of 
the  upper  air-passages  and  the  bronchial  tubes.  These  changes  may  be 
restricted,  in  the  lungs,  to  the  trachea  and  larger  bronchi,  or  they  may 
extend  to  the  finest  twigs.  They  may  amount  to  great  thickening  and 
deep  capillary  injections  of  the  mucous  lining  of  the  tubes,  which  contain 
at  the  same  time  clear,  frothy  mucus,  or  thick,  viscid  masses  of  muco-puru- 
lent  secretion  unmixed  with  air. 

More  or  less  congestion  of  the  gastric  mucous  membrane,  and  more 
rarely  of  that  of  the  intestine,  is  also  met  with.  The  solitary  and  agmi- 
nate glands  of  the  intestine  are  not  affected  save  as  the  result  of  special 
complications.  A  few  observations  relate  to  the  finding  of  enlarged  and 
softened  bronchial  glands.  More  extended  researches  are  needed,  not 
only  upon  this  point,  but  also  in  the  whole  domain  of  the  pathological 
anatomy  of  the  disease. 

Hyperremia,  oedema,  hypostatic  congestions,  splenization,  catarrhal 
pneumonia,  and  hepatization,  affect  the  lung-tissue  in  cases  fatal  by  the 
complications  which  are  associated  with  such  changes.  The  tissue-changes 
of  diseases  existing  prior  to  the  attack  of  influenza,  such  as  old  catarrhal 
consolidations,  tubercle,  brown  induration,  emphysema,  and  so  forth,  are 
of  course  frequently  discovered  at  the  necroscopy. 


Diagnosis. 

The  discrimination  of  influenza  from  other  affections  having  some 
points  of  resemblance  to  it,  is,  under  ordinary  circumstances,  unattended 
with   difficulty.      The   march   of   the   epidemic,   the  number    of   persons 


38  THE    CONTINUED   FEVERS. 

attacked,  the  prominence  of  the  nervous  symptoms,  the  rapidly  developed 
debility,  and  the  character  of  the  cough,  usually  severe  out  of  proportion 
to  the  physical  signs,  distinguish  it  from  all  other  epidemic  diseases. 

It  is  only  to  be  differentiated  from  non-specific  catarrhal  affections 
attended  by  fever,  considerable  malaise,  weakness,  severe  headache,  and 
pain  in  the  extremities,  by  a  due  regard  to  the  causative  relations  of  the 
two  affections.  Simple  catarrhs  not  rarely  present  the  group  of  symp- 
toms which  characterize  epidemic  catarrhal  fever,  but  they  occur  almost 
constantly  as  the  result  of  great  and  sudden  changes  in  the  weather,  and 
are  therefore  met  with  in  greatest  frequency  in  bad  seasons,  and  are  par- 
ticularly common  at  the  end  of  winter  and  in  the  spring. 

Influenza  is  not  in  any  way  dependent  upon  the  vicissitudes  of  the 
seasons,  and  may  occur,  as  has  been  shown,  at  all  times  of  the  year,  in  wet 
or  dry,  mild  or  cold  seasons,  equally,  and  in  every  variety  of  climate.  It 
is  of  course  diagnosticated  without  difficulty  from  the  sporadic  catarrhal 
fevers,  which  lack  the  characteristic  depression,  neuralgic  and  rheumatoid 
pains,  the  irritative  cough,  dyspnoea,  and  so  on. 

Cases  of  influenza  are  met  with  that  bear  a  strong  resemblance  to 
beginning  enteric  fever.  Malaise,  headache,  obtunded  hearing,  mental 
depression,  high  fever,  coated  tongue,  tender  belly,  diarrhoea,  are  symp- 
toms to  be  observed  in  both  affections.  But  influenza  lacks  the  tempera- 
ture-curve, the  usually  rapid  pulse,  the  splenic  enlargement,  and  the 
eruption  of  enteric  fever,  and  the  progress  of  the  disease  will  in  a  few 
days  clear  up  the  most  doubtful  cases. 


Pkognosis  and  Mortality. 

A  fatal  issue  is  rare  in  uncomplicated  cases.  The  very  young  bear 
influenza  badly;  the  old  bear  it  more  badly  still.  Nevertheless,  children 
have  enjoyed  a  considerable  proportionate  immunity  in  some  epidemics. 
Healthy  persons  in  the  middle  periods  of  life  bear  it  well.  Certain  pre- 
existing diseases  modify  its  course  unfavorably.  Among  these  are  chro- 
nic bronchitis,  emphysema,  and  fatty  heart.  The  debility  of  advanced 
phthisis  and  other  exhausting  diseases  render  influenza  dangerous.  Death 
takes  place,  in  by  far  the  greatest  number  of  cases,  as  the  result  of  the 
complication  of  the  attack,  either  with  some  pre-existing  affection,  or  with 
an  acute  disease  arising  in  its  course.  The  commonest  of  the  latter  are 
inflammations  of  the  parenchyma  of  the  lungs. 

Patients  presenting  very  severe  symptoms  generally  recover  if  they 
be  not  the  subjects  of  complicating  maladies,  or  very  young  or  very 
old. 

Relapses  are  not  uncommon  ;  second  attacks  have  been  known  to 
occur  during  the  continuance  of  an  epidemic  ;  it  is  often  the  case  that  an 


INFLUENZA.  39 

individual  in  the  course  of  his  life  passes  through  several  epidemics  of 
influenza  and  is  the  subject  of  the  disease  in  each  of  them. 

The  prognosis  is  greatly  modified  by  the  character  of  the  prevailing 
epidemic.  In  some  epidemics  the  deaths  are  few,  and  the  mortality  from 
other  diseases  does  not  appear  to  be  greatly  augmented.  In  others, 
many  die  of  the  epidemic  disease,  and  the  fatality  of  certain  endemic 
affections  is  markedly  increased.  In  some  of  the  older  epidemics  the* 
high  mortality  was  doubtless  due  to  injudicious  measures  of  treatment, 
among  which  bloodletting  and  otlier  depressing  agencies  were  conspicuous. 
Some  of  the  older  accounts  also  warrant  the  suspicion  that  a  coexisting 
typhus  had  to  do  with  the  high  death-rate.  It  is  estimated  that  in  the 
epidemic  of  1837,  which  was  a  very  severe  one,  two  per  cent,  of  those 
attacked,  died.  The  proportion  of  fatal  cases  in  particular  epidemics, 
varies  in  different  countries  and  even  in  different  quarters  of  the  same 
city. 

Treatment. 

No  efficient  means  of  prophylaxis  are  known.  Unfavorable  hygienic 
surroundings,  overcrowding,  a  damp,  unhealthy  locality,  appear  to  in- 
crease the  prevalence  and  severity  of  influenza.  The  opposite  conditions 
of  living  do  not,  however,  secure  immunity  from  the  attack.  During  an 
epidemic,  young  infants,  aged  persons,  those  enfeebled  by  chronic  diseases, 
and  in  particular  those  subject  to  chronic  bronchitis,  consumption,  emphy- 
sema, and  fatty  heart,  should  be  cared  for  with  unusual  diligence  and 
solicitude,  since  they  constitute  the  classes  most  prone  to  the  graver  com- 
plications of  the  disease,  and  from  which  its  fatal  cases  are  almost  wholly 
derived.  Such  individuals  should  be  warmly  clad  ;  they  should  shun,  as 
far  as  possible,  the  vicissitudes  of  the  weather,  even  if  practicable  keeping 
■within  warmed  and  well-ventilated  apartments;  they  should  exercise  un- 
usual prudence  in  diet  and  lead  a  carefully  regulated  life,  with  long  hours 
of  sleep.  It  is  true  that  these  measures  are  not  preventive  of  the  attack. 
Families  not  quitting  the  house,  living  in  the  greatest  seclusion,  even  the 
bedridden,  do  not  always,  or  even  as  a  rule,  escape.  Yet  it  has  frequently 
been  observed  that  those  whose  occupations  are  carried  on  in  the  open 
air  are  attacked  earliest  and  in  greatest  numbers.  On  the  other  hand,  in 
some  instances,  persons  isolated  from  the  community  with  strictness — in 
prisons,  cloisters,  hospitals — have  remained  free  from  the  disease  prevail- 
ing around  them.  It  therefore  appears  probable  that,  under  certain  fav- 
orable circumstances,  not  as  yet  perfectly  understood,  the  avoidance  of 
the  open  air,  and  of  the  direct  influences  of  the  weather,  may  confer  some 
degree  of  immunity  from  the  attack,  and  it  is  desirable  that  the  class  of 
persons  most  liable  to  the  graver  consequences  of  the  disease  should  avail 
themselves  of  even  the  most  uncertain  precautions. 


I 


40  THE    CONTINUED    FEVERS. 

The  treatment  of  influenza  is  expectant  and  supporting.  Not  only  is 
the  epidemic  self-limiting-,  tending  to  exhaust  the  susceptibility  of  the  in- 
fected community,  as  we  have  seen  in  most  instances,  in  the  space  of  a 
few  weeks,  but  the  attack  is  also  of  definite  duration,  and  the  perturba- 
tions set  up  by  the  action  of  the  influenza-poison  upon  the  individual  sub- 
side spontaneously  in  three  or  four,  or  at  most,  ten  or  twelve  days.  The 
susceptibility  of  the  individual  is  also,  for  the  time  being,  exhausted;  for 
second  attacks  in  the  same  epidemic  are  not  very  common.  In  cases  where 
the  duration  of  the  attack  is  prolonged  beyond  the  period  indicated,  it  is 
kept  up  by  complications,  and  we  have  to  do  not  so  much  with  the  patho- 
logical processes  of  influenza,  as  with  secondary  diseases  that  the  influenza 
has  excited,  either  by  the  intensity  of  its  action  or  by  reason  of  some  pe- 
culiarity of  the  subject  of  the  attack. 

By  far  the  greatest  number  of  cases  are  light  and  unattended  by  real 
danger.  The  treatment  is,  therefore,  for  the  most  part,  an  extremely  sim- 
ple one. 

These  lighter  cases  rarely  require  medical  measures.  The  patients 
are  uncomfortable  and  anxious,  easily  fatigued  and  unfitted  for  busi- 
ness. It  is  best  that  they  keep  the  house,  and,  if  willing,  the  bed  or  sofa, 
for  the  space  of  two  or  three  days.  The  diet  should  be  restricted  to  a  few 
simple  and  easily  digested  dishes.  Meat  should  be  avoided.  Parkes  re- 
gards the  common  custom  of  taking  hot  beef-tea  as  an  extremely  bad  one. 
He  thinks  that  it  invariably  increases  the  headache  and  languor,  and 
agrees  with  Pearson  that  warm  foods,  which  force  sweating,  are  not  only 
useless,  but  that  they  also  do  harm.  Moderate  quantities  of  cold  drinks 
may  be  taken.  The  fruit-syrups,  lemonade,  raspberry  vinegar,  a  weak 
solution  of  citrate  of  potash,  or  of  cream  of  tartar,  and  barley-water  with 
lemon,  are  useful.  Very  weak  wine-whey  is  often  liked.  The  efferves- 
cing mineral  waters  will  be  preferred  by  some.  The  best  of  such  drinks 
is  the  mixture  of  equal  parts  of  iced  seltzer-water  and  milk.  If  the 
stomach  be  irritable,  koumiss  may  be  tried  as  a  combined  beverage  and 
food.  In  the  mild  cases  stimulants  are  not  always  needed.  Some  of 
the  older  writers  think  them  positively  injurious  in  the  early  stages  of 
the  disease.  Sound  claret,  with  or  without  seltzer-water,  is  not  contra- 
indicated. 

Quinine  in  moderate  doses  should  be  taken  from  the  onset.  The  head- 
pains  are  not  increased  by  it.  Dover's  powder,  if  well  borne,  should  be 
taken  at  night.  Some  form  of  opiate  may  be  required,  even  in  mild  cases, 
to  counteract  wakefulness.  A  compressed  pill,  containing  extract  of 
opium  0.030  gramme  (gr.  ^),  camphor  0.135  gramme  (gr.  ij.),  and  am- 
monium carbonate  0.1G5  gramme  (gr.  ijss.),  will  be  found  useful  when  Do- 
ver's powder  cannot  be  employed.  During  convalescence,  iron  and  barks 
will  often  be  requisite. 

The  coryza,  tonsillitis,  laryngitis,  bronchitis,  are  to  be  treated  according 


INFLUENZA.  41 

to  general  principles,  if  they  require  treatment  at  all.  In  most  mild  cases 
the  catarrhal  symptoms  call  for  no  special  measures  of  treatment. 

Free  inunctions  of  fatty  substances  about  the  brow  and  over  the  bridge 
of  the  nose  may  be  of  use  as  regards  the  coryza. 

Morphine  dissolved  in  cherry-laurel  water,  one  part  in  fifty  or  sixty, 
is  recommended  by  Zuelzer  for  the  relief  of  the  head-pains  associated 
■with  the  coryza.  A  few  drops  may  be  snuffed  up  from  time  to  time.  These 
pains  are  of  a  surety  mitigated  to  some  degree  by  wearing  a  flannel  cap, 
or  wrapping  the  head  in  a  silk  handkerchief.  Warm  applications  some- 
times give  comfort,  while  cold  almost  invariably  adds  to  the  distress. 

Distress  in  the  upper  air-passages,  and  the  tickling  cough,  call  for 
steam  inhalations,  and  the  air  of  the  apartment  may  be  rendered  moist 
by  the  evaporation  of  water  kept  boiling  in  a  broad,  shallow  vessel. 

Gargles  of  potassium  chlorate,  or  potassium  chlorate  combined  with 
sumac,  exert  a  soothing  influence  upon  the  congested  tonsils. 

Severe  cases  call  for  more  energetic  measures  of  treatment. 

The  more  prominent  indications  are  the  control  of  the  fever;  the  di- 
minution of  the  hypersemic  fluxion  to  the  mucous  tracts;  the  arrest  of 
increasing  debility  ;  measures  of  support;  the  mitigation  of  pain  and  the 
induction  of  sleep  ;  and  finally,  the  prevention  of  the  pulmonary  conges- 
tion, to  which  the  depression  leads,  by  enfeeblement  of  the  circulation. 
The  last  indication  is  especially  urgent  in  infants,  the  very  old,  and  those 
previously  debilitated  from  any  cause. 

Inflammatory  complications  require  special  treatment  or  modifications 
of  treatment. 

The  febrile  movement  is  not,  as  a  rule,  high;  grave  nervous  symptoms 
and  serious  catarrh  may  be  associated  with  moderate  fever.  The  manage- 
ment of  the  fever  must  be  in  accordance  with  views  expressed  in  the 
Introduction,  regard  being  had  to  the  tendency  to  depression  which  is  so 
prominent  an  element  in  almost  every  case  of  influenza. 

An  antifebrile  regimen  is  to  be  observed.  The  moderate  duration  of 
this  fever,  as  compared  with  enteric  fever,  renders  it  less  important  that 
large  amounts  of  fever-food  should  be  given,  while  the  tendency  to  de- 
pression makes  it  of  the  utmost  importance  that  the  administration  of  food 
be  systematic  and  carefully  looked  after  by  the  medical  attendant.  The 
disinclination  to  take  food  is  so  great  that  it  is  often  v^ith  difficulty  that 
a  sufficient  quantity  can  be  given  in  the  early  days  of  the  attack,  and  it  is 
to  be  doubted  whether  benefit  follows  anything  in  excess  of  the  most 
moderate  amount.  It  is  necessary  to  observe  regular  hours,  as  in  the 
management  of  all  the  low  fevers.  As  soon  as  convalescence  begins  the 
patient  should  be  urged  to  eat;  the  quantity  of  food  taken  at  once  is  to 
be  augmented,  and  the  intervals  between  the  periods  of  its  being  offered 
are  to  be  lengthened. 

A  favorable  action  upon  the  excretory  function  of  the  skin  and  kidneys 


42  THE    CONTINUED    FEVERS. 

will  result  from  the  free  drinking  of  water,  or  of  the  beverages  spoken 
of  already.  In  all  cases,  at  least  enough  fluid  should  be  taken  to  relieve 
thirst. 

Diaphoretics  have  been  much  used,  upon  the  theory  that  by  determi- 
nation to  the  skin  they  correspondingly  diminish  the  tendency  to  hyper- 
aemia  of  the  affected  mucous  tracts.  Dover's  powder,  solution  of  the 
acetate  of  ammonia,  and  other  mild  diaphoretics,  are  to  be  selected.  Jabo- 
randi  should  be  employed  with  great  caution.  The  wet  pack  and  other 
hydrotherapeutic  measures  have  been  employed  in  Germany  to  act  upon 
the  skin  and  to  effect  a  direct  reduction  of  temperature  in  influenza.  For 
old  and  feeble  persons  warm  packs  are  to  be  employed.  A  profuse 
sweating  at  the  onset  of  the  attack  is  said  to  occasionally  cut  it  short. 
Biermer  states  that  early  diaphoresis  often  brings  about  a  rapid  and  lasting 
amelioration  of  the  symptoms.  It  is  to  be  borne  in  mind  that  the  fever 
is  rarely  excessive,  and  that  sweating  is  not  infrequently  a  troublesome 
symptom.     In  some  epidemics  it  has  been  a  very  troublesome  one. 

General  bloodletting  is  not  to  be  resorted  to  in  influenza.  Its  danger 
was  apparent  to  some  of  the  early  writers.  As  has  been  pointed  out,  the 
high  mortality  of  some  of  the  older  epidemics  is  to  be  explained  by  the 
venesections  practised  at  the  beginning,  and  even  during  the  course  of  the 
attack.  It  has  no  favorable  effect  upon  the  catarrhal  processes,  and  but 
little  upon  the  subjective  symptoms.  Parkes  states  that  the  fever  is  not 
relieved  by  it ;  the  nervous  depression  is  increased  and  the  risk  of  lung- 
congestion  is  augmented.  Bleeding  is  not  likely  to  be  practised  in  epi- 
demic catarrhal  fever  while  the  present  views  of  its  place  in  therapeutics 
continue  to  influence  practice.  Cautious  local  bloodletting,  for  the  relief 
of  local  inflammatory  trouble,  is  spoken  of  in  most  of  the  modern  books. 
It  seems  to  me  that  the  occasion  for  its  emplo\'ment  must  be  so  rare  in  the 
treatment  of  this  disease,  that  the  statement  may  be  henceforth  omitted. 
In  influenza,  as  it  is  known  to  medical  men  of  the  present,  from  the  de- 
scriptions of  the  old  and  personal  experience  of  the  few  recent  and  milder 
epidemics,  bloodletting,  either  general  or  local,  is  clearly  uncalled  for. 

Emetics  hold  a  high  historical  place.  It  was  of  old  customary  to  be- 
gin the  treatment  with  a  vomit.  As  late  as  the  epidemic  of  1837,  I/om- 
bard,  of  Geneva,  believed  that  they  shortened  the  attack  and  lessened  the 
intensity  of  the  symptoms,  when  administered  at  the  beginning.  In  cases 
attended  by  a  good  deal  of  early  gastric  disturbance  and  nausea,  they  are 
said  to  be  of  vast  use.  They  sometimes  set  up  great  irritability  of  the 
stomach,  with  vomiting  that  it  is  difficult  to  control.  On  the  whole,  the 
cases  in  which  an  emetic  would  do  good  must  be  extremely  rare.  Pur- 
gatives were  formerly  regarded  as  important  in  the  treatment.  This  view 
no  longer  prevails.  In  case  of  constipation,  gentle  purgation,  ex  indica- 
tione  symptomatica,  is  a  necessary  part  of  the  proper  management  of  the 
case.     For  this  purpose  the  laxative  mineral  waters,  as  Friederichshalle, 


INFLUENZA.  43 

Hunyadi,  Pullna,  are  excellent.  Castor-oil  may  be  given,  and  calomel  is 
in  some  cases,  and  particularly  in  childhood,  of  great  service.  Simple  ene- 
mata  of  warm  water,  or  soap  and  water,  will  often  sufiSce.  The  tendency 
in  some  cases  to  exhausting  and  troublesome  diarrhoea,  and  the  fact  that 
diarrhoea  occurs  sometimes  in  the  course  of  the  largest  number  of  cases, 
should  inspire  caution  in  the  use  of  purgatives.  Repeated  purgation 
during  the  progress  of  the  attack  is  not  only  useless — it  is  positively  in- 
jurious. 

Quinine  is  to  be  given  in  full  doses.  It  exerts  at  the  same  time  a 
powerful  influence  upon  the  temperature,  upon  the  tendency  to  local  hy- 
peraemias  and  upon  the  nervous  symptoms,  and  in  particular  the  headache. 
Da  Costa  states  that  its  use  is  of  "  primary  importance,"  and  Rawlins,'  as 
early  as  1833,  states  that  excellent  results  followed  its  administration,  the 
effect  being  the  better  the  earlier  it  was  given.  It  has  even  been  lauded 
as  a  specific  for  influenza. 

The  mineral  acids  may  be  given,  with  a  view  to  realizing  their  anti- 
febrile and  tonic  effects. 

For  the  most  part,  the  foregoing  measures  directed  against  the  fever, 
will  exert  a  favorable  influence  upon  the  catarrhal  processes.  Expecto- 
rants are  recommended  ;  ipecac  is  preferred.  The  preparations  of  anti- 
mony are  inadmissible  by  reason  of  their  tendency  to  depress.  Ammo- 
nium chloride  is  indicated  in  the  earlier  stajres  of  the  bronchitis.  Amonjj 
recent  drugs,  yerba  santa  (eryodiction  glutinosum)  and  the  oil  of  euca- 
lyptus, are  likely  to  prove  of  use  in  mitigating  the  symptoms  in  epidemic 
catarrh,  as  they  do  in  certain  forms  of  simple,  sporadic  catarrh. 

It  is  of  great  importance  that  the  peculiar  dry,  racking  cough,  so  often 
present  in  the  early  days  of  the  attack,  should  be  relieved.  It  is  not  useful 
in  removing  bronchial  accumulations,  being,  as  has  been  shown,  in  most 
instances  out  of  proportion  to  the  lesions  of  the  bronchial  mucous  mem- 
brane; on  the  other  hand,  it  tends  to  increase  the  hypersemia  of  the  upper 
air-passages  by  the  mechanical  violence  of  the  cough-paroxysms.  Further, 
it  is  distressing  and  exhausting,  and,  if  uncontrolled,  contributes  to  the 
muscular  and  nervous  prostration.  Benefit  will  be  derived  from  keeping 
the  air  of  the  apartment  moist,  and  from  the  occasional  inhalation  of  the 
steam  from  hot  water,  either  used  alone  or  poured  upon  the  compound 
tincture  of  benzoin,  a  pint  to  the  teaspoonf  ul,  or  upon  paregoric,  a  pint  to 
the  tablespoonful,  in  a  proper  vessel  or  inhaler. 

No  drugs  are  more  potent  to  this  end  thari  opium  and  its  derivatives, 
and  in  particular  morphia  and  codeia.  The  hypodermic  use  of  the  mor- 
phia salts,  judiciously  resorted  to,  constitutes  our  most  valuable  thera- 
peutic resource  in  fulfilling  the  threefold  indication  of  relieving  cough, 
alleviating  both  the  head-pain  and  the  pains  in  the  extremities,  and  in 

'  London  Medical  Gazette.     May,  1833. 


44  THE    CONTINUED    FEVEES. 

procuring  sleep.  The  former  dread  of  opium  in  bad  cases  was  not  well 
founded.  Its  moderate  administration  is  attended  with  advantages  that 
far  outweigh  any  danger  of  increasing  the  tightness  across  the  chest  and 
retarding  expectoration.  It  is  necessary  to  observe  the  same  or  even 
greater  caution,  in  giving  it  to  infants  and  aged  persons  in  influenza,  that 
is  essential  under  other  circumstances.  The  favorable  influence  of  car- 
bolic acid  in  restraining  cough  makes  it  probable  that  it  would  be  of 
great  service  in  this  disease.  It  may  be  combined  with  codeia  as  fol- 
lows: 

^ .  Acidi  carbolic!  liq 0.  530  c.c.         VI  viij. 

Codeine  sulph 0.  530  gram,     gr.  viij. 

Aquae  lauro-cerasi, 

Aqufe aa  32  c.c.  aa  f.  ^  j. 

M.  Signa. — A  teaspoon ful  q.  s.  h. 

The  chest-pains  and  substernal  pains  may  be  combated  with  sina- 
pisms, turpentine  stupes,  repeated  inunctions  of  fatty  substances  contain- 
ing extract  of  belladonna  and  the  like.  Pleurodynic  stitches  call  for 
similar  measures;  a  long  strip  of  machine-spread  belladonna-plaster  about; 
5  ctm.  (two  inches)  in  width,  applied  very  firmly  to  the  side  of  the  chest 
from  the  spine  in  a  direction  downward  and  forward  parallel  with  the^ 
ribs,  and  reaching  to  the  median  line  in  front,  affords  great  relief  to  the 
lateral  chest-pains. 

The  control  of  the  debility  must  be  regarded  as  the  most  important 
indication  in  old  and  feeble  persons.  Wine,  spirits,  milk-punch,  ammo- 
nia, spirits  of  chloroform,  are  to  be  used,  not  in  accordance  with  fixed  rules, 
but  as  occasion  may  require.  In  many  cases  wine  or  whiskey  will  be  in- 
dicated from  the  beginning,  the  quantity  being  determined  rather  by  the 
effect  upon  the  circulation  and  the  general  condition  of  the  case,  than  by 
rule.  Women  and  others  unaccustomed  to  the  use  of  alcoholic  drinks, 
often,  as  Da  Costa  states,  take  wine  and  brandy  in  considerable  quanti- 
ties, with  striking  benefit  and  without  flushing  or  other  evidences  of  its 
disagreeing. 

Chloral  is  inadmissible  as  a  hypnotic  by  reason  of  its  depressing  effect 
upon  the  heart.  The  bromides  may  be  used  in  connection  with  opium,  if 
the  latter  alone  be  not  well  borne. 

Diarrhoea  must  be  managed  in  accordance  with  general  principles.  If 
slight,  it  does  not  require  special  treatment.  It  is  apt  to  occur  at  one 
period  or  another  in  the  course  of  most  cases,  and  not  infrequently  marks 
the  beginning  of  convalescence.  Colic  may  be  treated  with  warm  fomen- 
tations and  carminatives;  if  it  be  due  to  constipation,  mild  laxatives  are 
to  be  combined  with  them. 

Severe  cases  of  influenza  demand  the  careful  attention  of  the  physi- 


INFLUENZA.  45 

cian,  who  must  be  on  the  alert  to  detect  the  inflammatory  lung- complica- 
tions which  so  often  lead  up  to  the  fatal  issue,  as  early  as  possible.  Their 
treatment  must  be  regulated  by  the  circumstances  of  the  case,  the  nature 
of  the  particular  complication,  the  age  of  the  patient,  and  so  on,  in  accord- 
ance with  general  therapeutical  indications. 

In  conclusion,  it  is  to  be  urged  that  all  measures,  of  whatever  kind, 
that  tend  to  depress  the  general  nervous  system,  or  the  functional  activity 
of  the  respiration,  and  especially  the  heart-power,  are  to  be  sedulously 
avoided  in  the  management  of  influenza. 

During  the  convalescence  good  nursing  and  abundant  nourishment  are 
needed  to  build  up  the  strength.  Unfavorable  influences  of  the  weather 
are  to  be  guarded  against.  It  is  important  to  warn  the  patient  that  a 
severe  attack  of  influenza  renders  him  liable  for  some  time  afterward  to 
pulmonary  disorders.  The  sequels,  and  in  particular  those  implicating  the 
respiratory  tract,  are  to  be  appropriately  treated.  A  course  of  tonics, 
iron  and  quinine,  and  the  like,  is  nearly  always  useful,  and  a  brief  change 
of  climate  is  often  of  advantage. 


III. 

CEREBRO-SPmAL  FEYER. 

DEFiNmoN. — A  malignant  continued  fever,  occurring  in  general  or  lim- 
ited epidemics  and  caused  by  some  unknown  specific  external  influ- 
ence. It  is  of  sudden  onset,  mostly  of  rapid  course,  and  very  fatal. 
The  symptoms  point  to  profound  disturbance  of  the  functions  of  the 
brain  and  spinal  cord;  associated  headache,  vomiting,  and  painful 
contraction  of  the  muscles  of  the  back  of  the  neck,  are  characteristic. 
Delirium,  stupor,  coma,  cutaneous  hypersesthesia,  and  motor  palsies 
occur.  In  many  instances  eruptions,  chiefly  herpetic  and  petechial, 
attend  the  disease.  There  is  uniformly  great  nervous  depression. 
The  lesions  found  after  death  are  constant,  varying  only  in  the  de- 
gree of  their  development.  They  are  the  results  of  an  acute  diffuse 
inflammation  of  the  pia  mater  of  the  brain  and  spinal  cord,  and  con- 
sist of  intense  hyperasmia  with  dense  cell-infiltration,  and  fibrino- 
purulent  exudation. 

Synonyms. — Epidemic  cerebro-spinal  meningitis  ;  Epidemic  meningitis; 
Fever  with  cerebro-spinal  meningitis;  Cerebro-spinal  arachnitis;  Ty- 
phus syncopalis  ;  Cerebro-spinal  typhus;  Cerebral  typhus;  Typhus 
cerebralis  apoplecticus;  Petechial  fever;  Malignant  purpuric  fever; 
Malignant  purpura;  Pestilential  purpura;  Febris  nigra;  Fievre  ce- 
rebrale;  Phrenesie;  Cephalalgie  epidemique;  Meningite  cerebro-rha- 
chidienne;  Meningite  purulente  epidemique  (France);  Febbre  so- 
poroso-convulsiva;  tifo  apoplectico  tetanico  (Italy);  Nacksjucka; 
Dragsjucka  (Sweden);  Genick  Krampf;  Genickstarre;  Hirnseuche 
(Germany) ;  Spotted  fever;  Congestive  fever  ;  Cold  plague. 

As  our  knowledge  of  a  disease  becomes  more  exact,  and  we  are  en- 
abled to  discriminate  it  as  a  substantive  affection  from  maladies  which 
resemble  it,  the  names  by  which  it  is  designated  become  fewer  in  number 
and  more  precise.  The  long  list  of  synonyms  for  cerebro-spinal  fever, 
given  above,  is  rather  of  historical  than  of  present  practical  interest. 
Many  of  them  have  been  employed  in  ignorance  of  the  real  nature  of  the 
disease,  and  their  multiplicity  has  arisen  in  part  from  that  ignorance,  by 


CEREBRO-SPIKAL    FEVER.  47 

which  observers  were  led  to  confound  it  with  other  diseases,  and  particu- 
larly with  typhus,  and  in  part  from  the  great  variety  of  forms  which  the 
disease  assumes  in  different  epidemics.  It  is  only  within  two  decades 
that  careful  attention  has  been  generally  directed  to  the  study  of  the  ana- 
tomical lesions  which  almost  constantly  occur,  and  which  on  the  one 
hand  explain  to  a  great  extent  many  of  the  symptoms  that  are  charac- 
teristic, and  on  the  other  separate  the  affection  from  all  other  diseases 
which  it  in  any  way  resembles.  It  is  only,  therefore,  within  comparatively 
recent  years  that  distinctive  terms  embodying  the  idea  of  the  localized 
lesions  have  been  applied  to  it.  With  the  introduction  of  these  names, 
due  to  such  a  knowledge  of  the  nature  of  the  disease  as  enables  the  pro- 
fession to  diagnosticate  it  from  other  affections  with  precision,  other 
names  for  it,  not  embodying  the  idea  of  the  spinal  lesions,  nor  that  of  its 
being  a  distinct  affection,  as  well  as  those  derived  from  symptoms  neither 
constant  nor  characteristic,  have  become  obsolete. 

As  will  appear  from  the  following  account  of  the  disease,  it  is  a  gen- 
eral affection  of  febrile  character,  and  is  therefore  properly  described 
among  the  fevers.  The  fever  is  of  continued  type  ;  it  is  for  that  reason 
classed  with  the  continued  fevers.  It  is  not  symptomatic  of  the  local 
inflammatory  processes,  which  are,  however,  constant.  The  term  cere- 
bro-spinal  fever,  or  epidemic  cerebro-spinal  fever,  appears  to  be,  for  the 
reasons  just  given,  preferable  to  that  of  epidemic  meningitis,  or  cere- 
bro-spinal meningitis,  and  finds  its  analogue  in  enteric  fever,  the  only 
other  of  the  continued  fevers  attended  by  a  constant  anatomical  lesion. 
The  affection  is  designated  cerebro-spinal  fever  in  "  The  Nomenclature  of 
Disease  "  of  the  Royal  College  of  Physicians,  and  this  term,  indicating  as 
it  does  the  infectious  character  of  the  malady  and  the  anatomical  seat  of 
the  constant  lesion,  has,  in  the  present  state  of  nosology,  the  warrant  of 
sound  logic  and  is  worthy  of  general  adoption. 


Historical  Sketch. 

Cerebro-spinal  fever  was  first  recognized  as  a  distinct  affection  about 
the  beginning  of  the  present  century.  It  is  to  be  conceded  to  those 
writers  who  have  sought  to  show  that  it  has  existed  from  a  remote  period, 
that  their  opinion  is  probably  correct,  for  the  first  recognition  of  an  infec- 
tious disease  as  an  independent  affection  is  more  likely  to  mark  a  period 
of  advance  in  medical  science  than  the  period  of  origin  of  the  disease. 
Doubtless  many  accounts  of  epidemics  of  unusual  forms  of  fever  with 
cerebral  symptoms,  recorded  by  the  older  writers,  included  cases  of  this 
disease,  but  the  fact  cannot  be  established  by  adequate  proof.  In  truth, 
it  is  only  in  the  light  of  knowledge  obtained  later  in  the  century  by  sys- 
tematic post-mortem  investigations,  that  the  earlier  epidemics,  described 


48  THE    CONTINUED    FEVERS. 

by  numerous  observers  both  in  America  and  Europe,  under  many  differ- 
ent names,  are  now  to  be  recognized  as  instances  of  the  disease  under  con- 
sideration. 

The  history  of  cerebro-spinal  fever  must  then  begin  with  the  circum- 
scribed epidemics  which  occurred  nearly  simultaneously  in  Middle  Europe 
and  in  the  United  States,  shortly  after  the  setting-in  of  the  present  cen- 
tury. 

Of  these,  the  first  of  which  we  have  any  record  arose  in  Geneva  and 
its  environs,  in  February,  1805.  The  disease  appeared  at  nearly  the  same 
time  in  different  parts  of  the  city,  and  prevailed  until  April.  This  out- 
break was  described  by  Vieusseux,'  whose  account  remains,  according  to 
Hirsch,"  the  only  contribution  to  the  knowledge  of  this  affection  which 
Las  come  to  us  out  of  Switzerland. 

The  researches  of  Stille  '  have  brought  to  light  the  fact  that  the  dis- 
ease prevailed  in  Prussia,  Holland,  the  Rhine  Provinces,  Bavaria,  and  the 
east  of  France,  but  not  elsewhere  in  Europe,  in  limited  epidemics  during 
every  one  of  the  following  years,  until  1816.  An  epidemic  occurred  at 
Grenoble,  in  1814,  which  attracted  some  attention.  In  the  same  year  an 
outbreak  of  the  disease  occurred  in  Paris,  and  in  the  following  year  (1815) 
at  Metz.  These  three  visitations  were  almost  exclusively  confined  to  the 
garrisons. 

Meanwhile,  it  arose  in  the  United  States  at  Medfield,  in  Massachusetts, 
in  the  year  1806,  and  prevailed  at  various  points  in  New  England,  Canada, 
the  State  of  New  York,  Pennsylvania,  and  elsewhere  in  the  Western  and 
Southern  States,  from  that  year  until  1816. 

Hirsch  is  unwilling  to  regard  these  early  American  outbreaks,  which 
were  described  by  those  who  observed  them  under  such  names  as  "  Sink- 
ing Typhus,"  "  Typhus  Syncopalis,"  and  "  Spotted  Fever,"  as  instances 
of  the  disease  under  consideration,  and  goes  so  far  as  to  discuss  them  un- 
der the  heading  "  Typhus  Syncopalis  "  as  a  form  of  typhus.*  This  opinion 
he  reiterates  with  emphasis  in  his  work  *  on  Cerebro-spinal  Meningitis, 
published  later.  Nevertheless,  the  evidence  in  the  various  accounts  pub- 
lished at  the  time  has  been  sufficient  to  convince  most  American  writers 
upon  the  subject  that  these  epidemics  were,  in  fact,  outbreaks  of  cerebro- 
spinal fever. 

This  view  is  also  held  by  Radcliffe  in  his  scholarly  article  upon  the 

'  Joum.  gencr.  de  med.,  xxiv. ,  p.  163. 

"  A,  Hirsch :  Handbuch  der  historisch-geograpliischen  Pathologie.  Erlangen, 
1864. 

*  Alfred  Stille  :  Epidemic  Meningitis,  or  Cerebro-spinal  Meningitis.  Philadelphia, 
1867. 

*  Band  I.,  p.  165. 

*  A.  Hirsch  :  Die  Meningitis  Cerebro-spinalis  Epidemica.  Berlin,  1866.  P.  11,  foot- 
note. 


i 


CEREBRO-SPINAL    FEVEE.  49 


subject,  in  Reynolds's  System  of  Medicine,'  and  may  be  accepted  as  cor^ 
rect.  No  record  of  the  occurrence  of  the  disease  from  the  year  1816  ex- 
ists, until  1822,  when,  during  the  spring,  numerous  cases  appeared  in 
Vesoul,  in  France.  This  epidemic  chiefly  affected  the  civil  population. 
According  to  Ziemssen,"  the  symptoms  of  a  disease  which  prevailed  in 
Dorsten  during  the  winter  of  1822-23,  and  was  described  as  a  "  myelitis, 
sometimes  complicated  with  encephalitis,"  correspond  with  those  of  cere- 
bro-spinal  meningitis. 

At  each  of  these  places  the  appearance  of  the  disease  was  limited 
both  as  to  the  locality  and  the  duration  of  the  epidemic.  Stille  informs 
us  that  it  prevailed  in  a  like  local  and  temporary  measure  in  1823,  at 
Middletown,  Conn.;  in  1828  in  Trumbull  County,  O.;  in  1830  at  Sunder- 
land, England,  and  in  1833  at  Naples. 

A  period  of  quiet  ensued.  During  four  years  nothing  further  was 
heard  of  the  disease.  But  in  the  early  part  of  the  year  1837  it  again 
made  its  appearance  in  France.  This  outbreak  was  the  beginning  of  a 
widely  extended  and  long-continued  prevalence  of  cerebro-spinal  fever. 
Its  ravages  were  no  longer  confined  to  a  restricted  locality  or  to  a  season. 

From  the  Pyrenean  frontier  in  the  southwest,  where  it  was  first  felt  in 
Bayonne,  and  from  the  south,  where  it  made  its  appearance  a  little  later 
in  the  same  year  (1837),  at  Foix  and  Narbonne,  it  spread  in  a  northerly  di- 
rection over  the  greater  part  of  France,  the  middle  regions  and  the  high 
table-lands  alone  escaping. 

Almost  at  the  same  time  it  broke  out  in  Dax,  Auch,  Perpignan,  and  in 
Bordeaux.  It  visited  La  Rochelle  in  the  same  year,  and  early  in  1838  showed 
itself  in  Rochefort,  being  at  first  confined  to  a  regiment  that  had  come  from 
the  department  of  Landes  in  the  south,  in  which  the  disease  was  prevail- 
ing. It  prevailed  from  1838  to  1842  in  the  southeast  of  France,  and  par- 
ticularly along  the  valley  of  the  Rhone.  The  garrisons  of  Toulon,  Mar- 
seilles, Nismes,  Avignon,  and  other  cities,  suffered.  During  four  years 
foHowing  1838  the  disease  showed  itself  successively  among  the  troops 
stationed  at  Metz,  where  it  prevailed  during  the  winter  of  1839-40;  Stras- 
bourg, where  it  appeared  in  the  autumn  of  1840  and  continued  till  the  fol- 
lowing summer,  affecting  the  civil  community  also  ;  Nancy,  early  in  1841, 
where,  with  the  single  exception  of  a  lady  dwelling  in  the  city,  its  ravages 
were  restricted  to  the  soldiery,  and  Colmar,  where,  in  the  spring  of  1842, 
scattered  cases  occurred  in  the  garrison. 

Early  in  1839  cerebro-spinal  fever  broke  out  in  Versailles,  and  it  is 
worthy  of  remark  that  the  first  cases  occurred  in  the  very  same  regiment 
from  the  department  of  Landes  in  which  it  first  showed  itself  the  previous 
year  at  Rochefort,  and  which  had  come  at  the  end  of  the  year  1838  from 

'  A  System  of  Medicine,  edited  by  I.  Russell  Reynolds.    Vol.  ii.    Philadelphia,  1868. 
•  Cyclopsedia  of  the  Practice  of  Medicine.   Vol.  ii.     Amer.  ed.     New  York,  1875. 
4 


50  THE    CONTINUED    FEVERS. 

Rochefort  to  Versailles.  This  outbreak  was  confined  to  the  garrison.  Fronr. 
this  time  until  1843  it  prevailed  among  the  military  forces  in  and  around 
Paris.  A  little  later  the  disease  appeared  at  various  points  in  the  valley  of 
the  Loire.  We  first  encounter  it  here  in  the  spring  of  1840  at  Laval,  where 
it  prevailed  until  the  following  year,  being  confined  to  the  soldiery  until 
the  close  of  the  epidemic,  when  a  few  scattered  cases  broke  out  among  the 
civil  population.  In  the  winter  of  1840-41,  many  cases  were  observed  at 
Le  Mans,  and  at  Chateau-Gonthier;  at  the  last-named  place  among  troops 
that  had  come  from  Laval.  The  same  and  the  following  winter,  cerebro- 
spinal fever  appeared  either  as  an  epidemic,  or  with  notable  frequency,  at 
Poitiers,  Tours,  Blois,  Ancenis,  and  in  the  early  part  of  the  year  1842  it 
showed  itself  at  Nantes,  not  far  from  the  mouth  of  the  Loire,  where  it 
spread  indifferently  among  the  soldiers  and  citizens.  In  1840-41,  it  visited 
the  northwest  coast  and  prevailed  in  Brest,  Cherbourg,  and  Caen.  In 
1842  it  appeared  in  Lyons.  With  the  close  of  that  year  the  virulence  of 
the  disease  in  France  seems  to  have  passed  away,  for,  although  it  con- 
tinued to  occur  in  that  country  until  the  winter  of  1848-49,  the  outbreaks 
were  limited,  and  in  most  instances  took  place  in  localities  previously 
visited  by  the  disease  in  its  epidemic  form. 

At  the  period  when  the  disease  began  to  spread  itself  over  wide  areas 
in  France,  namely,  during  the  winter  of  1839-40,  it  entered  Italy,  where 
it  continued  to  prevail  until  1845.  It  first  appeared  at  Naples  and  at 
various  points  in  the  Papal  States,  but  the  following  winter  it  spread  over 
the  greater  part  of  the  kingdom. 

The  same  year  cerebro-spinal  fever  made  its  appearance  in  Algiers, 
where  it  prevailed  in  an  epidemic  form  at  various  points,  and  in  particu- 
lar in  the  central  and  eastern  districts,  until  1847,  selecting  its  victims 
among  the  civil  population,  both  native  and  European,  as  well  as  among 
the  troops. 

In  the  spring  of  1844  a  transient  outbreak  took  place  at  Gibraltar. 
The  civil  population  chiefly  suffered,  only  a  few  scattered  cases  occurring 
among  the  British  troops  of  the  station. 

Denmark  felt  the  scourge  in  1845.  During  the  spring  it  prevailed 
as  an  epidemic  in  parts  of  Jutland,  while  elsewhere,  and  especially  in 
Zealand  and  in  the  city  of  Copenhagen,  many  scattered  cases  occurred. 
In  the  winters  of  1846-47  and  1847-48,  it  again  appeared,  but  in  an  en- 
demic rather  than  an  epidemic  form. 

The  year  1846  brought  the  malady  into  the  British  Islands.  Here, 
however,  its  ravages  were  relatively  limited.  It  broke  out  in  several  work- 
houses of  Dublin  and  Belfast,  and  a  number  of  cases  occurred  among  the 
citizens  of  Dublin.  In  the  spring  of  the  same  year  many  cases  were  ob- 
served in  Liverpool,  though  the  disease  cannot  be  said  to  have  assumed 
the  proportions  of  an  epidemic. 

While  the  disease  was  thus  spreading  over  Europe,  it  again  visited  the 


CEREBKO-SPINAL    FEVER.  51 

United  States,  It  made  its  appearance  in  this  country  in  the  beginning 
of  the  year  1842,  at  points  widely  distant  from  each  other  and  remote 
from  intercourse  with  the  Old  World.  Outbreaks  occurred  at  about  the 
same  time  at  Louisville,  Ky,,  in  Tennessee,  and  at  Montgomery,  Ala. 
During  the  following  years  until  1850,  a  series  of  epidemics  took  place  in 
Arkansas,  Mississippi,  Illinois,  Pennsylvania,  Massachusetts,  New  York, 
and  North  Carolina.  In  1848,  Montgomery,  Ala.,  was  a  second  time 
visited.  In  January  and  February,  1850,  New  Orleans  suffered,  and  with 
this,  the  last  of  the  local  epidemics,  the  long  prevalence  of  cerebro-spinal 
fever  in  the  Western  hemisphere  came,  for  the  time,  to  an  end,  almost 
simultaneously  with  its  temporary  extinction  in  Europe. 

For  four  years  cerebro-spinal  fever  ceased  its  ravages  in  the  Old 
World.  So  far  as  can  be  learned,  the  New  World  enjoyed  a  longer  period 
of  immunity  ;  but  the  disease  had  ceased  to  rage,  not  to  exist. 

Suddenly,  in  the  early  part  of  the  winter  of  1854,  it  made  its  appear- 
ance in  Sweden,  a  country  which  had,  up  to  this  date,  escaped.  In  no 
land  that  this  terrible  disease  had  scourged  in  previous  epidemics  had  its 
prevalence  been  so  general  and  so  destructive.  It  continued  until  1861. 
Hirsch  has  pointed  out  this  peculiarity  of  the  Swedish  epidemic,  that,  start- 
ing from  the  province  of  Gothenburg,  in  the  Skagerrack,  in  the  southwest, 
it  crept  steadily  toward  the  north,  cases  occurring  in  every  season  of  the 
year,  and  districts  affected  one  year  almost  wholly  escaping  the  next  ; 
while  the  southern  boundary  of  the  new  area  visited  by  the  disease,  cor- 
responded very  nearly  with  the  northern  boundary  of  that  in  which  it  had 
existed  the  year  before.  Strange  to  say,  Norway  wholly  escaped  until 
1859,  when  the  fury  of  the  disease  was  beginning  to  abate  in  Sweden,  and 
then  experienced  it  only  in  circumscribed  outbreaks. 

Scarcely  had  the  epidemic  in  Sweden  ceased  when  the  disease  appeared 
in  the  Netherlands — winter  of  1860-61,  and  the  next  winter  witnessed  a 
very  general  outbreak  in  Portugal. 

A  little  later,  Germany,  which,  with  the  exception  of  slight  epidemics 
early  in  the  century,  had  almost  entirely  escaped  the  ravages  of  cerebro- 
spinal fever,  became  the  seat  ofc  a  severe  and  long-continued  epidemic. 
The  disease  appeared  in  the  north  in  the  summer  of  1863  ;  it  spread  rap- 
idly, but  at  no  place  assumed  the  form  of  a  severe  epidemic.  Middle 
Germany  felt  it  in  1864,  from  April  to  September,  and  again  after  an  in- 
terval of  several  months — in  February,  1865,  when  an  extensive  outbreak' 
took  place  at  Eisenach  and  the  neighboring  districts.  The  prevalence  of 
the  disease  at  this  time  became  much  more  alarming  in  Southern  Germany. 
It  was  first  observed  by  Ziemssen  at  Erlangen,  in  July,  1864,  but  it  was 
not  until  the  following  winter  that  it  became  distinctly  epidemic.  This 
author  regards  it  as  probable  that  its  earliest  appearance  dates  farther 
back,  as  five  cases  of  fatal  suppurative  cerebral  meningitis  were  examined 
post-mortem  at  the  Polyclinic  in  Erlangen,  in  the  winter  of  1862-63.  The 


52  THE    CONTINUED    FEVERS, 

violence  of  the  disease  in  Germany  seems  to  have  abated  toward  the  close 
of  the  year  18G5.  Traces  of  it  were,  however,  met  with  till  1872.  Ziems- 
scn  regards  it  as  naturalized  in  Germany,  Small  and  circumscribed  epi- 
demics appeared  at  various  points  in  the  Austrian  Empire  during  the 
period  from  1865  to  1867.  It  again  prevailed  to  some  extent  in  Vienna 
in  1872. 

The  most  extended,  and  at  the  same  time  the  most  destructive  out- 
break that  has  visited  the  British  Isles,  showed  itself  in  Ireland  in  March, 
1866,  and  reached  its  greatest  development  in  the  following  winter,  Dub- 
lin suffered  chiefly  ;  many  of  the  smaller  towns  had  each  a  few  cases  ; 
the  soldiery  supplied  proportionately  more  cases  than  the  civil  population, 
as  in  the  French  epidemics  ;  the  disease  was  almost  wholly  restricted  to 
Ireland.  The  continued  freedom  from  this  disease  which  Scotland  has 
enjoyed  is  most  remarkable. 

It  existed  in  Russia  from  1864  to  1868,  and  was  encountered  in  the 
beginning  of  1868  in  the  Crimea. 

Small  epidemics  were  observed  in  Turkey,  Greece,  Asia  Minor,  Smyrna, 
and  Jerusalem,  between  1868  and  1872.  These  visitations  were  not  char- 
acterized by  great  severity.  On  this  side  the  Atlantic,  from  the  time  of 
the  outbreak  in  New  Orleans  in  1850,  no  epidemic  arose  until  1856.  Dur- 
ing this  year  it  appeared  in  North  Carolina,  and  continued  to  prevail  in 
that  State  till  1857  ;  in  the  latter  year  it  broke  out  in  the  central  and  west- 
ern parts  of  the  State  of  New  York,  where  it  raged  in  its  most  malignant 
form.  The  same  year  Massachusetts  became  the  seat  of  a  somewhat  ex- 
tensive epidemic. 

In  1861-62,  it  appeared  in  Missouri,  both  among  the  troops  and  the 
civil  population,  and  almost  at  the  same  time  in  the  army  encamped  in 
the  vicinity  of  Washington,  D.  C.  The  same  year  we  read  of  it  in  Indi- 
ana, Kentucky,  and  Connecticut.  In  1862-63,  it  attacked  the  troops  in 
Newbern,  and  this  and  the  following  winter  those  at  Memphis,  Tenn. 
Ohio  felt  its  ravages  from  1860  to  1864,  and  within  this  period  the  inhab- 
itants of  Illinois,  Rhode  Island,  New  Jersey,  Pennsylvania,  and  most  of 
the  Southern  States  suffered  from  it.  I«  1872,  it  prevailed  extensively  in 
the  city  of  New  York  and  its  environs. 

It  made  its  appearance  in  Philadelphia  in  1863,  and  prevailed  annually 
in  an  epidemic  form  until  toward  the  close  of  the  last  decade,  while  occa- 
sional cases  were  observed  up  to  1873,  in  which  year  a  small  but  fatal 
epidemic  prevailed  in  every  district  of  the  city,  even  those  most  widely 
separated.     Since  1873  it  has  not  occurred  here  as  an  epidemic. 

Within  the  last  few  years  cases  of  cerebro-spinal  fever  have  been  ob- 
served from  time  to  time  in  localities  in  which  it  has  prevailed  earlier  as 
an  epidemic.  These  cases  have  occurred  sometimes  singly,  oftener  in  small 
groups.  The  remark  of  Ziemssen,  that  the  disease  appears  to  have  become 
naturalized  in  Germany,  seems  also  to  hold  good  of  our  own  and  of  other 


CEREBRO-SPINAL    FEVER.  53 

countries  that  it  has  scourged.  Cases  have  recently  been  observed  in  Ire- 
land, France,  Austria,  and  at  Warsaw,  and  on  this  side  the  Atlantic  in  St. 
Louis  and  Atlanta  ;  but  the  disease  fortunately  is  at  this  time  nowhere 
epidemic. 

But,  in  studying  the  history  of  this  strange  disease,  our  attention 
is  attracted  to  the  fact  that  it  is  not  alone  in  those  regions  that  have 
known  it  in  its  epidemic  form  that  cases  and  groups  of  cases  afterward 
occur;  but  that  such  extremely  restricted  outbreaks  also  take  place  in 
countries  where  it  has  never  been,  so  far  as  we  know,  epidemic.  Eng- 
land is  a  notable  and  authentic  instance  of  such  a  country.  Cerebro- 
spinal fever  has  never  prevailed  in  that  island  as  an  epidemic.  With  the 
exception  of  a  number  of  cases  that  broke  out  in  Liverpool  in  the  year 
1846,  it  has  been  rarely  met  with  within  her  borders,  and  then  only  in 
single  cases  or  small  groups  of  cases.  Thus,  in  1807,  four  cases  were  ob- 
served by  Dr.  Gervis,  of  Ashburton.  A  single  case  was  seen  by  Dr.  Wilks 
in  each  of  the  three  years,  1856,  1858,  1859,  in  London  ;  in  1859,  Dr.  Day 
saw  two  cases  at  Stafford,  and  another  at  the  same  place  in  1865  ;  in  the 
same  year  three  cases  were  seen  by  Dr.  Wilks  in  London,  three  by  Dr. 
Ogle,  and  one  by  Dr.  Martin. 

The  foregoing  historical  notes  indicate  in  a  general  way  the  march  of 
the  disease  and  the  geographical  limits  within  which  it  has  thus  far  shown 
itself.  They  are  the  record  of  outbreaks  that  have  fallen  under  the  notice 
of  medical  men  who  have  published  their  observations.  Without  doubt 
they  imperfectly  outline  its  actual  distribution  and  prevalence  ;  yet  we 
are  warranted  in  assuming  that  no  extensive  outbreak  has  escaped  notice, 
and  that  the  appearance  of  so  formidable  an  affection  elsewhere  on  the 
civilized  globe  would  have  been  known  and  recorded. 

Stille  suggests  that  the  history  of  cerebro-spinal  fever,  during  the  pres- 
ent century,  may  be  divided  into  three  periods,  each  of  which  comprises 
the  account  of  a  widespread  prevalence  of  the  disease  upon  both  sides  of 
the  Atlantic,  lasting  for  a  series  of  years.  The  first  of  these  outbreaks 
lasted  eleven  years,  from  1805  to  1816  ;  the  second,  thirteen  years,  from 
1837  to  1850  ;  and  the  third,  which  began  in  Europe  in  1854,  and  in  North 
America  in  1856,  was  still  in  force  at  the  time  of  the  issue  of  his  book 
(1867).  It  came  to  a  close,  however,  in  1873,  after  a  continuance  of  from 
seventeen  to  nineteen  years,  with,  however,  a  period  of  repose  in  the 
United  States  from  1857  to  1861.  If  this  view  be  correct  and  the  out- 
breaks described  are  in  fact  distinct  epidemics,  separated  by  intervals  in 
which  the  affection  does  not  occur,  it  is  to  be  looked  upon  as  a  true  pan- 
demic— seeing  that  it  appears  in  places  as  widely  separated  as  Europe 
and  America  at  nearly  the  same  time,  and  overruns  the  greater  part  of  a 
continent.  In  this  respect  cerebro-spinal  fever  resembles  influenza;  but 
it  differs  from  it  in  recurring  from  season  to  season  during  a  long  term  of 
years. 


54  THE    CONTINUED    FEVERS. 

It  is  to  be  remembered,  however,  as  a  matter  of  fact,  that  in  the  periods 
of  non-activity,  cases  and  even  small  epidemics  of  the  disease  have  been 
observed,  as  at  Vesoul  and  Dorsten,  at  Naples,  and  in  this  country  in 
Connecticut  and  Ohio,  as  recorded  by  Dr.  Stille  himself,  and  that  in  re- 
cent years  occasional  limited  outbreaks  have  led  so  careful  an  observer  as 
Ziemssen  to  believe  that  the  disease  has  been  an  abiding  one  in  Europe. 

There  is  thus  some  warrant  for  regarding  cerebro-spinal  fever,  contrary 
to  the  suggestion  of  Stille,  as  having  had  during  the  century  a  continued 
existence  within  certain  geographical  limits,  as  having  had  its  periods  of 
epidemic  outbreak  and  its  periods  of  quiescence,  but  never  as  having 
wholly  ceased  to  exist  within  those  limits,  or  as  having  disappeared  in  the 
same  sense  that  cholera  and  influenza  disappear  from  the  same  countries 
in  the  intervals  of  their  epidemic  visitation. 

If  we  call  to  mind  the  fact  that  the  disease  under  consideration  was 
not  at  all  known  as  a  substantive  affection  until  early  in  this  century,  and 
that  for  many  years  it  was  regarded  as  a  variety  of  typhus  fever  by  most 
practitioners  and  by  many  learned  writers  upon  epidemic  diseases,  it  will 
not  appear  unreasonable  to  assume  as  probable  that  many  isolated  cases 
and  small  groups  of  cases  may  have  occurred  during  the  periods  of  qui- 
escence between  1816  and  1822,  between  1822-23  and  1833,  between  1833 
and  1837,  and  between  1850  and  1854-56,  and  yet  have  failed  to  find  their 
way  into  print  and  to  the  general  knowledge  of  the  medical  profession. 
Surely,  in  view  of  our  knowledge  of  such  cases  during  recent  years,  it  is 
entirely  within  the  range  of  possibility  that  instances  of  cerebro-spinal 
fever  have  escaped  recognition  as  such,  at  periods  when  its  pathological 
anatomy  was  little  understood,  and  the  great  majority  of  medical  men 
were  ignorant  of  its  existence  as  a  distinct  affection. 

It  has  been  stated  that  the  lower  animals  are  subject  to  this  disease, 
that  it  is  at  times  epizootic  as  well  as  epidemic.  It  is  well  known  that 
the  epidemic  in  New  York,  in  1872,  was  preceded  for  some  months  by 
the  prevalence  of  a  disease  among  the  horses,  which  presented  the  same 
symptoms  and  post-mortem  appearances.  In  no  case  was  it  observed  to 
spread  directly  to  the  stablemen,  veterinary  surgeons,  or  others  having 
charge  of  them  ;  and  upon  the  appearance  of  the  affection  as  an  epi- 
demic at  a  later  period,  those  persons  were  not  found  to  be  more  liable  to 
its  attack  than  others, 

Cerebro-spinal  fever  presents  certain  peculiarities  in  its  mode  of  at- 
tack, its  extension,  its  course  and  duration  as  an  epidemic  disease,  that 
separate  it  widely  from  other  epidemic  diseases,  and  which  it  seems  pro- 
per to  consider  at  this  point  in  the  discussion. 

First,  of  its  mode  of  invasion.  The  disease  has  more  than  once  broken 
out  with  activity  almost  at  the  same  time  in  the  New  and  the  Old  World; 
in  many  instances  it  has  appeared  simultaneously  at  points  as  far  distant 
from  each  as  the  diameter  of  a  kingdom,  while  the  intermediate  regions 


CEREBRO-SPINAL    FEVER.  55 

have  remained  free  from  it,  not  only  while  it  raged  in  the  points  attacked, 
but  afterward.  This  was  the  case  in  many  of  the  epidemics  of  France 
and  Algiers,  in  those  which  occurred  in  Ireland,  and  in  those  which  vis- 
ited the  United  States,  especially  in  the  earlier  history  of  the  disease. 
It  is  also  true  that  in  general  epidemics,  such  as  have  prevailed  in  Swe- 
den, some  portions  of  Germany,  and  in  districts  of  our  own  country,  cer- 
tain localities  in  the  midst  of  the  infected  regions  have  wholly,  or  almost 
wholly,  escaped  its  ravages. 

Secondly,  this  fever  differs  from  other  epidemic  diseases  in  its  mode 
of  extension.  In  general  epidemics  it  has  much  more  frequently  been 
observed  to  spread  by  a  series  of  isolated  outbreaks  of  irregular  distribu- 
tion than  by  a  direct  advance  from  place  to  place,  or  by  radiating  lines 
from  an  infected  centre.  This  is  not,  however,  an  invariable  rule,  as  is 
seen,  for  example,  in  some  of  the  French  epidemics,  where  the  advance  of 
the  disease  went  hand  in  hand  with  the  movements  of  troops,  or  where  it 
corresponded  with  the  course  of  a  i-iver,  as  in  the  epidemics  which  tra- 
versed the  valley  of  the  Loire;  or  in  that  great  series  of  epidemics  which 
passed  over  Sweden  from  the  southwest  toward  the  north.  When,  how- 
ever, we  trace  the  march  of  the  disease  more  closely  in  these  and  similar 
epidemics,  we  are  struck  with  the  fact  that  its  progress  is  still  by  a  series 
of  isolated  outbreaks — not,  in  these  cases,  of  irregular  distribution,  but  in 
the  general  direction  of  the  line  of  advance. 

Not  less  remarkable  is  the  course  of  the  disease  in  an  infected  popula- 
tion. The  wide  geographical  distribution  sketched  in  the  above  account 
by  no  means  represents  a  general  diffusion  among  the  inhabitants  of  the 
cities,  districts,  and  countries  in  which  it  has  prevailed.  Scattered  cases 
and  groups  of  cases  may  occur  over  a  wide  area,  without  any  great  ten- 
dency to  a  concentration  of  the  violence  of  the  epidemic,  as  in  the  Swed- 
ish and  most  of  the  German  epidemics;  while,  on  the  other  hand,  the 
whole  number  of  cases  may  occur  within  restricted  limits,  the  latter  being 
the  more  common  rule.  Many  epidemics  have  attacked  a  single  class  in 
the  community.  This  was  the  case  in  France,  in  1837  and  the  following 
years,  when  the  disease  chiefly  affected  the  soldiery,  often  being  confined 
to  a  garrison,  or  a  section  of  a  garrison,  sometimes  even  to  a  single  regi- 
ment, without  extending  to  the  surrounding  populations,  and  in  1844, 
at  Gibraltar,  where  the  civil  population  bore  the  brunt  of  the  attack. 
The  same  limitation  of  the  cases  to  a  class  among  the  people  was  ob- 
served during  the  epidemic  in  Italy,  where  in  1840  an  outbreak  at  Pro- 
cida  was  almost  exclusively  confined  to  the  convicts  in  the  galleys;  in 
Ireland,  where  in  1846  the  inhabitants  of  the  workhouses  principally  suf- 
fered; and  in  the  late  American  war,  at  Newbern,  Memphis,  and  in  the 
neighborhood  of  Washington,  where  the  troops  alone  suffered. 

Finally,  this  disease  presents  remarkable  differences  from  other  epi- 
demic diseases,  in  regard  to  its  duration  as  an  epidemic.     In  this  respect 


56  THE    CONTINUED    FEVERS. 

it  has,  at  different  places  and  in  different  outbreaks,  shown  the  most  ex- 
treme variations.  The  greatest  number  of  epidemics  have  lasted  from 
three  to  six  months;  others  have  been  of  shorter  duration,  coming  to  an 
end  in  a  few  weeks,  while  it  has  frequently  happened  that  new  cases 
have  appeared  throughout  an  entire  year,  or  from  the  spring  of  one  year 
till  the  end  of  the  following  winter.  The  duration  of  the  epidemic  de- 
pends upon  causes  not  yet  known.  It  cannot  be  said  to  be  influenced  by 
the  size  of  the  population,  for  on  one  hand  we  read  of  comparatively  brief 
outbreaks  in  populous  cities  like  Berlin,  Vienna,  and  on  the  other  of  lin- 
gering epidemics  in  such  relatively  sparsely  inhabited  countries  as  Algiers 
and  Sweden. 

The  epidemics  are  often,  in  spite  of  a  duration  of  several  months  or 
even  of  a  year  or  more,  limited  to  a  relatively  small  number  of  cases  in 
the  infected  community — a  few  individuals  here  and  there  being  attacked, 
and  the  mortality  being  moderate.  In  other  instances,  on  the  contrary, 
considerable  numbers  suffer  and  the  death-rate  is  high,  and,  as  Hirsch 
points  out,  the  proportionate  number  of  persons  attacked,  and  of  fatal 
cases,  are  not  seldom  in  inverse  ratio  to  the  duration  of  the  epidemic,  a 
relatively  great  number  of  cases  occurring,  with  a  high  mortality,  in  epi- 
demics that  came  to  an  end  in  a  few  (six  to  eight)  weeks. 

Sometimes  the  outbreaks  do  not,  as  is  the  case  with  most  epidemic 
diseases,  rise  steadily  to  an  acme  and  then  gradually  decline,  but  seem 
to  run  an  irregularly  intermittent  course,  a  number  of  persons  being  at- 
tacked, then  the  disease  to  all  appearance  vanishing,  only,  however,  to 
return  after  a  time  to  seize  new  victims,  and  this  disappearance  and  re- 
turn being  repeated  till  the  close  of  the  epidemic,  after  many  weeks  or 
months. 

Etiology. 

The  cause  of  cerebro-spinal  fever  is  as  yet  unknown.  Much  less  "is 
known  of  the  laws  which  control  its  origin,  its  distribution,  its  action  in 
communities  and  upon  individuals,  than  is  known  of  the  active  causes  of 
most  of  the  other  infectious  diseases.  The  unaccountable  appearance  of 
the  disease  at  the  same  time  in  widely  separated  localities,  its  diffusion 
by  isolated  attacks  rather  than  by  direct  advance,  its  variable  and  often 
long-continued  prevalence  in  epidemics,  its  sporadic  occurrence  between 
the  epidemics,  the  extraordinary  diversity  of  the  symptoms  in  different 
epidemics  and  in  different  cases,  baffle  the  comprehension  and  render  fu- 
tile every  effort  to  formulate  even  a  satisfactory  hypothesis  of  its  cause 
and  origin. 

There  appears  to  be  no  longer  any  question  as  to  the  infectious  nature 
of  this  disease.  The  constant  local  lesions  suggest  the  idea  of  its  being 
essentially  an  inflammatory  process — to  this  suggestion  the  prominence 


CEREBRO-SPINAL    FEVER.  67 

and  constancy  of  the  symptoms  due  to  meningeal  inflammation  bear  sup- 
port; but  a  closer  examination  of  the  clinical  history  of  the  afPection,  and  a 
wider  study  of  its  pathological  anatomy  show  that  this  view  is  untenable. 

The  onset  of  cerebro-spinal  fever,  the  initial  chill,  and  the  febrile  phe- 
nomena, are  analogous  to  those  of  the  infectious  diseases,  especially  the 
eruptive  fevers.  The  rapid  course  of  the  attack  to  its  fatal  termination — 
which  often  takes  place  within  a  few  hours  at  the  beginning  and  at  the 
height  of  a  malignant  epidemic,  and  for  which  no  satisfactory  explanation 
is  found  in  the  lesions — is  without  parallel  in  simple  inflammations,  but  is 
not  infrequent  in  severe  infectious  diseases.  The  appearance  of  various 
eruptions,  and  especially  of  herpes,  and  the  rapidity  of  the  discoloration 
of  the  body  after  death,  also  point  to  the  infectious  character  of  this  dis- 
ease. But  when  we  come  to  consider  the  tissue-changes  outside  of  the 
region  of  the  cerebro-spinal  axis,  we  are  still  more  fully  impressed  with 
the  resemblance  which  exists  between  this  and  the  other  infectious  dis- 
eases. We  find  blood-changes,  and  degenerations  of  the  heart  and  the 
voluntary  muscles,  to  be  almost  always  present.  The  change  in  the  blood 
is  as  constant  as  the  meningeal  inflammation  and  exudation. 

Although  the  specific  cause  of  this,  as  of  other  infectious  diseases,  is 
not  known  to  us,  the  observations  of  the  past  quarter  of  a  century  furnish 
data  upon  which  to  base  knowledge  of  a  very  positive  kind  relative  to  its 
predisposing  causes. 

It  may  be  safely  asserted,  in  spite  of  the  fact  that  the  limits  within 
which  cerebro-spinal  fever  has  been  known  to  prevail  are  limited,  as 
compared  with  the  inhabited  surface  of  the  globe,  that  climate  has  no  di- 
rect influence  in  producing  this  disease.  Epidemics  have,  as  we  have  seen, 
occurred  in  the  Eastern  hemisphere,  in  Central  and  Western  Europe  and 
Algeria,  between  the  thirty-fifth  and  sixty-third  degrees  of  north  lati- 
tude— therefore  in  all  kinds  of  climates,  from  the  subtropical  of  the  Med- 
iterranean coast  to  the  rigorous  of  mid-Sweden.  In  the  Western  Hemi- 
sphere, the  range  has  scarcely  been  less  extensive,  for  we  meet  with 
records  of  the  disease  in  the  eastern  portions  of  North  America,  from  the 
Gulf  Coast  to  Canada,  a  territory  whose  southern  boundary  is  the  thirtieth 
and  whose  northern  boundary  is  about  the  forty -eighth  degree  of  north 
latitude,  and  which  embraces  the  greatest  variety  of  temperate  climate. 
The  disease  is  not  known  to  have  prevailed  within  the  tropics. 

The  season  of  the  year,  and  the  weather,  appear  to  exert  an  important 
influence.  Winter  and  the  cold  months  are  unquestionable  and  powerful 
predisposing  causes  of  epidemic  cerebro-spinal  fever.  Of  226  local  out- 
breaks in  France,  166  occurred  between  December  1st  and  May  31st, 
60  during  the  other  six  months  of  the  year;  while  in  Sweden,  of  397  local 
outbreaks,  311  took  place  in  the  former  period,  86  in  the  latter.'     In  the 

'  See  Hirsch  :  Die  Meningitis  Cerebro-spinalis  Epidemica,  p.  113.  The  figures  are 
incorrectly  given  by  Stille,  and  by  Radcliffe,  who  follows  him. 


58  TUE    CONTINUED    FEVERS. 

United  States  the  outbreaks  have  taken  place  with  great  uniformity  in 
the  winter  and  spring,  the  exceptions  to  this  rule  being  very  few. 

The  epidemics  which  have  occurred  in  the  winter  and  spring  have  usu- 
ally been  widely  extended,  the  outbreaks  of  the  summer  and  autumn  being 
milder  and  more  limited. 

We  possess  no  accurate  detailed  investigations  as  to  the  effect  of  tem- 
perature, moisture,  and  the  direction  of  the  wind. 

The  development  of  this  disease  is  clearly  favored  by  cold  weather,  yet 
it  is  impossible  to  say  in  what  way  this  agent  acts.  The  specific  cause 
of  the  disease,  the  fever-poison,  may  find  in  a  low  temperature  conditions 
favorable  to  its  existence,  or  the  influence  of  cold  upon  the  bodily  con- 
stitution may  call  forth  an  especial  predisposition  for  the  affection;  or, 
finally,  in  the  modifications  of  the  mode  of  life  peculiar  to  the  season  of 
cold  weather,  this  disease,  as  some  others,  may  find  the  conditions  most 
favorable  to  its  development. 

Locality  does  not  act  in  any  way  as  a  predisposing  cause  of  cerebro- 
spinal fever.  Low,  marshy  regions,  high  plateaus  and  the  inhabited  dis- 
tricts of  mountains,  have  alike  suffered  from  its  ravages.  The  condition 
of  the  soil  exerts  no  influence  upon  its  development.  It  has  prevailed  in 
swarripy  bottom-lands,  and  upon  dry,  sandy  soils,  if  not  with  equal  fre- 
quency, at  least  with  no  preference  for  one  or  the  other  that  the  records 
collected  make  manifest.  Densely  populated  cities  and  the  scattered 
populations  of  agricultural  regions,  may  alike  stand  in  terror  of  its  return, 
for  they  have  alike  known  its  horrors  in  the  past. 

In  contradistinction  to  locality  in  the  broad  sense  with  reference  to 
communities,  the  place  of  abode  and  the  mode  of  life  of  the  individual 
have  much  to  do  with  the  development  and  prevalence  of  this  fever. 
Damp,  overcrowded,  and  unclean  habitations  favor  it.  Those  living  wholly 
upon  the  ground  floor  are  apt  to  suffer.  Ziemssen  regards  the  overcrowd- 
ing of  dwelling-  and  sleeping-rooms,  and  the  consequent  loading  of  the 
air  with  animal  emanations,  and  perhaps  the  saturation  of  the  soil  with 
garbage  and  the  products  of  its  decomposition,  as  being  agents  as  power- 
ful in  the  germination  of  the  contagion  of  this  disease  as  they  are  in  that 
of  cholera. 

The  common  occurrence  of  limited  outbreaks  in  detached  dwellings,  in 
a  row  of  houses  or  a  street,  in  schools,  in  prisons,  in  workhouses,  as  in 
almost  every  one  of  the  Irish  epidemics,  and  in  garrisons,  as  in  most  of 
the  epidemics  in  France  in  1837  and  the  following  years — and  this,  in  most 
instances,  without  the  spreading  of  the  disease  to  the  civil  population, 
force  upon  us  the  conclusion  that  whatever  may  be  the  nature  of  the  spe- 
cific cause,  the  unfavorable  dwelling-place  of  the  individual  acts  as  a  pow- 
erful collateral  cause  of  the  disease.  That  such  conditions  are,  however, 
merely  collateral  causes  of  the  disease  and  altogether  inoperative  in  its 
production  in  the  absence  of  the  specific  cause,  is  made  clearly  manifest 


CEREBRO  SPINAL    FEVER.  59 

by  their  permanence  within  the  limits  of  its  merely  occasional  occurrence, 
and  in  other  localities  where  it  is  unknown. 

To  similar  unfavorable  modes  of  living  is  to  be  attributed  the  severity 
of  the  epidemics  that  have  so  often  prevailed  among  the  negroes  in  the 
South.  It  is  impossible  to  trace  any  direct  influence  of  race  as  a  predis- 
posing cause  of  cerebro-spinal  fever.  The  negro  is  not  more  susceptible 
to  it  than  others  living  under  the  same  unfavorable  hygienic  conditions  as 
did  the  slaves  formerly,  and  do  the  freedmen  of  to-day,  upon  the  cotton- 
and  rice-plantations. 

While  it  has  been  observed  in  by  far  the  greatest  number  of  outbreaks, 
that  those  subjected  to  privations  and  consequent  foulness  of  person  and 
dwelling,  by  reason  of  poverty,  suffered  most,  it  is  by  no  means  to  be  in- 
ferred that  the  opposite  conditions  of  life  secure  entire  immunity.  On  the 
contrary,  those  living  in  affluence  and  under  hygienic  conditions  of  the 
most  favorable  kind,  have  in  many  epidemics  fallen  victims  to  the  disease. 
In  the  United  States,  the  households  of  respectable,  well-to-do  farmers  have 
often  contributed  a  large  percentage  of  the  cases  in  infected  regions. 

It  may  be  stated,  as  a  general  rule,  that  in  adult  life  the  proportion  of 
males  attacked  is  much  greater  than  of  females.  In  some  outbreaks,  as 
where  the  disease  has  been  confined  to  a  garrison,  males  only  have  suffered; 
but  the  rule  holds  good,  where  civil  populations  alone  are  visited,  more  males 
than  females  suffer.  The  explanation  of  this  fact  lies  undoubtedly  in  the 
difference  of  the  mode  of  life  of  men  and  women  in  civilized  communities. 
It  is  to  be  observed,  however,  that  in  a  few  epidemics  the  females  at- 
tacked have  outnumbered  the  males  (Hirsch).  Among  children  the  num- 
ber of  males  and  females  is  nearly  equal. 

Age  is  of  the  greatest  importance  among  the  predisposing  causes. 
Immunity  is  reached  at  no  period  of  life.  Ziemssen  has  examined,  after 
death,  persons  as  old  as  seventy  and  seventy-seven  years;  beyond  forty, 
cases  are,  however,  rare;  more  common  between  twenty  and  forty  years, 
but  by  far  most  common  in  the  first  twenty  years  of  life.  In  many  epi- 
demics only  children  under  fifteen  years  have  been  attacked.  Of  1,267 
fatal  cases  occurring  in  Sweden  from  1855  to  1860  inclusive,  where  the 
age  was  stated,  889  were  under  fifteen  years,  328  between  sixteen  and 
forty,  and  50  over  forty  years  old.  Of  779  fatal  cases  of  which  statis- 
tics were  collected  by  Hirsch  in  the  districts  of  Carthaus  and  Brebant,  in 
Dantzig,  208  occurred  within  the  first  year  of  life,  337  between  the  first 
and  fifth  years,  151  between  the  fifth  and  tenth  years,  41  between  the 
tenth  and  fifteenth,  16  between  the  fifteenth  and  twentieth,  and  26  at  all 
ages  over  twenty. 

Again,  Dr.  Sanderson'  found  that,  in  the  Lower  Vistula,  21 8  fatal  cases 

'  A  Report  of  the  Results  of  an  Inquiry  into  the  Epidemics  of  Cerebro-spinal  Menin- 
gitis Prevailing  about  the  Lower  Vistula,  etc.  Official  paper.  Eighth  Report  of  the 
Medical  Office  of  the  Privy  Council.     London,  1865. 


60  THE    CONTINUED    FEVERS. 

were  under  the  age  of  fourteen  years,  and   only  seventeen  above  that 
age. 

Children  are  not  only  more  susceptible  to  the  disease,  but  the  death- 
rate  is  higher  during  cliildhood  than  at  any  other  period  of  life.  The 
fio-ures  given  above,  being  derived  from  mortuary  statistics,  are  mislead- 
ing, unless  due  allowance  be  made  for  the  fact  just  stated.  According  to 
the  official  report  of  the  cases  occurring  in  Central  Franconia,  from  June, 
1854,  to  the  date  of  the  report  in  1865,  as  quoted  by  Ziemssen,  of  456 
persons  attacked — 

257  were  from     0-  9  years  of  age. 
126  "  10-19     " 

41         "  20-29     " 

32  were  over         30     "         " 

Of  42  cases  observed  by  Ziemssen  himself — 

14  were  from     0-  9  years  of  age. 
13         "  10-19     "         " 

9         "  20-29     " 

6  were  over        30     "         " 

The  following  are  the  statistics  of  the  Board  of  Health  of  the  city  of 
New  York,  relative  to  the  age  of  the  persons  attacked: 


Of  975  cases — 


125  were  under  1  year  of  age. 


336     ' 

'      from 

1-  5 

years 

of  age 

204     ' 

(( 

5-10 

106     * 

(( 

10-15 

54    ' 

(( 

15-20 

79     * 

« 

20-30 

71     * 

over 

30 

Finally,  out  of  81  cases  coming  under  the  personal  knowledge  of  Dr. 
Smith,'  in  the  city  of  New  York — 

8  were  under  1  year  of  age. 
18     "      from   1-  3  years  of  age. 
20     "        "       3-  5     "         " 
17     "        *'       5-10     "         " 

7     "        "      10-15     "         " 
11     "      over         14     "  " 

All  occupations  and  professions  are  liable  to  this  disease.     Military 
life  appears  to  be  attended  with,  however,  an  especial  liability.     Most  of 

'  J.  Lewis  Smith,  M.D.  :  Cerebro -spinal  Fever,  with  Facts  and  Statistics  of  the  Re- 
cent Epidemic  in  New  York  City.  American  Journal  Medical  Sciences.    October,  1873. 


CEKEBRO-SPINAL    FEVER,  61 

the  epidemics  of  France  following  the  outbreak  of  1837  occurred  almost 
exclusively  among-  the  soldiery.  During  the  American  Civil  War  several 
outbreaks  occurred  among  the  troops,  without  extending  to  the  neigh- 
boring civil  populations. 

Military  observers  have  very  generally  regarded  unusual  exertion, 
hardship  and  fatigue,  especially  in  connection  with  exposure  to  cold,  as 
powerful  predisposing  causes.  These  influences  play  but  little  part  in 
the  production  of  the  disease  in  the  civil  population.  Nevertheless,  many 
observers  are  of  the  opinion  that  exciting  and  perturbating  influences  of 
some  sort  not  infrequently  precede  the  attack,  and  stand  in  a  causal  rela- 
tion to  it,  in  so  far  as  they  render  the  individual  prone  to  the  epidemic 
influence. 

Dr.  J.  Lewis  Smith  mentions  over-work,  fatigue,  mental  excitement, 
prolonged  abstinence  from  food,  followed  by  over-eating  and  the  use  of  im- 
proper and  indigestible  food,  as  rendering  the  subject  liable  to  the  attack. 
He  found  that  children  who  had  been  subjected  to  the  severe  discipline  of 
the  public  schools,  returning  home  tired  and  hungry,  and  eating  heartily 
at  a  late  hour,  were  especially  liable  to  the  attack.  The  condition  of  the 
individual,  as  regards  previous  health,  was  not  seen  to  exert  any  causal 
influence  of  importance.  Persons  attacked  are  generally  strong  and  in 
robust  health,  and,  as  has  been  seen,  in  the  earlier  periods  of  life. 
Chronic  invalids  do  not,  however,  escape,  nor  do  those  suffering  from 
other  acute  affections. 

But  these  influences,  however  potent  as  predisposing  causes  they  may 
be,  are  utterly  inadequate  to  the  production  of  cerebro-spinal  fever  in  the 
absence  of  the  single,  specific,  exciting  cause. 

The  nature  of  this  cause  is  unknown. 

It  can  no  longer  be  maintained  that  cerebro-spinal  fever  is  a  form  of 
typhus,  or  that  it  is  allied  to  it.  On  the  contrary,  it  is  now^  universally 
admitted  that  it  is  a  disease  sici  generis.  The  essential  point  of  differ- 
ence between  these  two  diseases  will  be  considered  under  the  head  of 
diagnosis. 

Still  less  can  this  disease  be  regarded  by  thoughtful  observers  as  a 
variety  of  malarial  fever.  It  can  be  readily  shown  that  between  the 
cause  or  infecting  principle  of  cerebro-spinal  fever  and  that  of  malarial 
diseases  there  exists  no  identity  whatever. 

Cerebro-spinal  fever  not  infrequently,  as  will  be  seen  when  we  come 
to  consider  its  clinical  history,  presents  a  distinctly  intermittent  course. 
For  this  reason  it  has  been  thought  that  some  relationship  between  the 
two  affections  exists. 

A  brief  consideration  of  the  following  points  shows  that  this  opinion 
cannot  be  maintained.  Cerebro-spinal  fever  shows  no  preference  for  ma- 
larious localities  ;  it  prevails  commonly  during  the  cold  weather  of  the 
winter  and  spring  months,  and  is  relatively  infrequent  in  the  seasons  in 


62  THE    CONTINUED    FEVERS. 

■which  malarious  diseases  are  rife  ;  thirdly,  when  it  prevails  in  malarious 
regions,  it  shows  neither  a  greater  malignancy,  nor  a  more  marked  ten- 
dency to  run  an  intermittent  or  remittent  course  than  it  does  in  high, 
sandy  regions,  where  native  malarial  fever  is  unknown  ;  and  in  conclu- 
sion, there  is,  beyond  the  tendency  of  the  fever  to  remit  and  intermit,  no 
further  resemblance  between  the  two  diseases.  Marked  enlargement  of 
the  spleen  is  not  common  in  cerebro-spinal  fever,  enlargement  of  tlie 
liver  is  not  one  of  its  sequels,  and  quinine  has  no  power  to  check  it,  even 
•when  its  course  most  closely  resembles  that  of  a  malarial  attack. 

Cerebro-spinal  fever  has  been  almost  unanimously  pronounced  to  be 
either  absolutely  non-contagious,  or  contagious  to  a  very  slight  degree, 
by  those  whose  observations  have  rendered  them  competent  to  judge  of 
the  matter.  The  vast  majority  of  cases  break  out  without  the  most  re- 
mote possibility  of  personal  communication.  The  cases  occurring  at  the 
beginning  of  an  epidemic  appear  here  and  there  in  the  community,  in  dis- 
tant quarters  of  a  city,  or  miles  apart  in  rural  districts.  As  the  disease 
spreads,  new  cases  and  groups  of  cases  arise  in  distant  localities  whose  in- 
habitants have  held  little  or  no  communication  with  the  sick  or  their  at- 
tendants. In  many  instances  only  one,  or  perhaps  two  members  of  a 
famil)',  are  attacked  throughout  the  course  of  an  epidemic.  The  members 
of  a  household  occupying  the  same  apartments,  or  passing  freely  in  and 
out  by  the  bedside  of  the  patient,  are  apparently  not  more  liable  to  con- 
tract the  disease  than  others  having  no  contact  with  the  sick,  unless  the 
dwelling  be  foul  and  ill-ventilated.  When  several  cases  occur  in  the  same 
house,  it  is  often  at  such  irregular  intervals  as  to  preclude  the  idea  of  in- 
fection at  the  same  time,  or  from  one  another,  as  the  periods  of  incubation 
of  the  contagious  disease  is  within  certain  limits,  uniform.  Thus,  Dr. 
Sewall,'  in  the  epidemic  of  1872  in  New  York  City,  met  with  an  instance 
where  six  cases  occurred  in  a  single  family,  but  at  intervals  of  five,  seven, 
eleven,  twenty-five,  and  forty -five  days  respectively.  In  the  same  epidemic 
Dr.  J.  Lewis  Smith  encountered  in  each  of  39  families  a  single  case,  in 
16  families  2  cases  each,  and  in  3  instances,  3  cases  in  a  family. 

It  is  a  notable  fact  that  physicians,  nurses,  and  other  attendants  upon 
the  sick  have  contracted  the  disease  only  in  the  rarest  instances,  and  pa- 
tients in  hospital  wards  into  which  cases  of  cerebro-spinal  fever  have  been 
brought  have  remained,  as  a  rule,  unaffected  by  the  cause  of  the  disease. 

In  view  of  the  foregoing  facts,  it  is  to  be  concluded  that  the  opinion 
so  universally  entertained  by  medical  men  who  have  made  this  disease 
the  subject  of  personal  study,  namely,  that  it  is  non-contagious,  is  correct; 
that  is  to  say,  that  it  is  not  contagious  in  the  sense  in  which  we  are  in  the 
habit  of  using  the  term  in  speaking  of  small-pox,  scarlet  fever,  t3'phus, 
etc.     But  that  it  is  capable  of  being  communicated  from  the  sick  to  the 

'  New  York  Medical  Record,  July  1,  1872. 


CEREBRO-SPINAL    FEVER.  63 

■well,  under  certain  favorable  circumstances  which  are  as  yet  unknown 
to  us — in  other  words,  that  it  is  in  a  modified  sense  contagious — seems 
probable.  The  difficulty  in  discussing  the  subject  of  the  contagiousness 
of  any  disease  arises  in  part  from  our  habit  of  using  the  word  in  its  broad- 
est and  most  positive  meaning,  as  when  we  speak  of  the  diseases  just 
named.  As  long  as  there  is  room  for  doubt  as  to  the  possibility  of  a  ma- 
lignant disease  spreading  by  contagion,  it  is,  from  a  practical  standpoint, 
important  to  regard  it  as  to  a  degree  contagious;  so  that,  if  errors  occur 
in  respect  of  this  point,  they  may  be  committed  on  the  right,  that  is  to 
say,  on  the  safe  side. 

Among  the  facts  which  suggest  the  possibility  of  the  specific  exciting 
cause  of  this  fever  being  communicable  from  one  person  to  another,  or  at 
least  portable  on  the  person  or  among  the  effects  of  those  who  have  been 
exposed  to  it,  are  the  following:  the  outbreaks  in  that  regiment  of  French 
soldiers  already  mentioned,  which,  having  suffered  from  the  disease  in 
Bayonne  in  1837,  again  suffered  from  it  in  1838,  after  having  been  trans- 
ferred to  Rochefort,  where  the  disease  had  not  previously  existed,  and  in 
which,  in  the  following  year,  it  having  been  transferred  to  Versailles,  the 
first  cases  of  a  lingering  but  limited  epidemic  again  sliowed  themselves  ; 
in  1840  the  disease  broke  out  at  Laval,  and  accompanied  the  troops 
marched  from  that  place  to  Mans  and  Chateau-Gonthier;  the  appearance 
of  the  disease  among  the  French  soldiers  in  Algiers,  in  1840,  at  a  time 
when  it  prevailed  extensively  in  the  army  in  France.  Hirsch  points  out 
the  importance  that  would  attach  to  this  extension  of  the  disease  across 
the  Mediterranean,  if  it  were  known  whether  or  not  the  malady  appeared 
first  among  troops  fresh  from  France.  The  same  authority  narrates  the 
following  reliable  observations: 

"According  to  Fraentzel,  the  first  case  of  the  disease  among  the  troops  in  Berlin 
was  in  one  of  the  reserve  of  the  Alexander  regiment,  who  a  few  days  before  had  come 
from  Leignitz,  where  the  meningitis  was  then  prevailing  as  an  epidemic.  In  the 
second  company  of  this  regiment,  to  which  he  belonged,  five  more  cases  afterward  oc- 
curred ;  in  the  two  companies  lying  adjacent  on  each  side,  there  were  three  cases  in 
one,  two  in  the  other ;  in  the  four  companies  beyond  them,  only  one  and  that  the 
lightest  case,  while  there  was  no  illness  at  all  in  the  second  battalion,  which  occupied 
the  same  barracks  and  was  separated  from  the  first  only  by  a  small  court,  the  two  bat- 
talions as  is  geue-ally  the  case,  associating  but  little  with  each  other,  but  sharing  in 
all  respects  the  same  labors  and  mode  of  life,  and  eventually  the  evils  of  over- 
crowding." 

Still  more  striking  is  the  following  observation  cited  by  Hirsch  as  oc- 
curring in  the  epidemic  of  West  Prussia,  in  1865: 

"On  February  8th,  K. ,  aged  twenty,  fell  ill  in  the  township  of  Sczakau.  He  was 
nursed  by  the  girl  W.,  who  had  hastened  to  him  out  of  the  village  of  Sullenczyn, 
After  the  death  of  K.  his  nurse  returned  home  and  there  died  on  February  26th,  of  epi- 
demic meningitis.     This  was,  with  the  exception  of  one  on  January  loth,  the  first  fatal 


64  THE    CONTINUED    FEVERS. 

case  of  meningitis  in  SuUenczyn.  To  the  burial  of  this  maid  came  the  family  of  the 
farm-steward  K. ,  to  SuUenczyn  from  the  township  of  Podgass,  accompanied  by  the 
servant  D.  and  the  four-year-old  daughter  O.  of  the  teacher  R.  in  Podgass.  After 
their  return  from  the  funeral,  a  little  child  of  K.'s  fell  ill  and  died  in  twenty -four 
hours,  then  the  servant  D.,  who  died  on  March  4th,  and  finally  the  girl  R.,  on 
March  7th." 

The  same  authority  cites  also  the  following  example: 

"  At  another  village,  two  chQdren  of  one  family,  aged  respectively  one  and  a  half 
and  three  and  a  half  years,  died  of  the  epidemic,  one  on  January  27th,  and  the  other 
on  February  7th.  The  clothes  of  the  deceased  were  taken  to  a  neighboring  village, 
and  came  into  the  possession  of  a  girl  aged  five  years.  She  soon  sickened  of  the  epi- 
demic, and  died  on  February  14th." 

The  following  cases  are  less  striking.  The  first  is  cited  by  Stokes,  the 
other  by  J.  Lewis  Smith  : 

"A  child  was  seized  with  epidemic  cerebrospinal  meningitis  and  died.  A  second 
child  of  the  same  family  was  attacked  with  the  malady  a  few  days  later.  The  day 
following  the  attack  of  this  child,  the  mother,  who  slept  in  the  same  bed  with  it,  sick- 
ened of  the  disease." 

"  A  boy,  twelve  years  of  age,  died  of  cerebro-spinal  fever,  and  was  buried  on  Satur- 
day or  Sunday.  On  the  following  Monday  the  mother  washed  the  linen  of  the  boy, 
which  had  accumulated,  and  within  two  days  was  herself  affected  with  the  disease. 
She  and  her  infant,  who  was  also  seized  with  it,  died." 

Such  instances  are  exceedingly  uncommon.  Were  they  less  so,  the 
argument  in  favor  of  the  contagious  nature  of  the  disease  would  be 
stronger. 

All  that  our  present  knowledge  warrants  us  in  saying  upon  this  point 
is  that  the  usual  mode  of  epidemic  spread  of  cerebro-spinal  fever  renders 
it  highly  probable  that  the  fever-producing  poison  is  of  the  nature  of  a 
miasm  which  becomes  active  at  places  remote  from  each  other  at  the  same 
time,  and  spreads  independently  of  human  intercourse;  while  in  rare  in- 
stances it  appears  to  have  been  carried  upon  the  persons  or  among  the 
personal  belongings  of  those  who  have  been  in  contact  with  the  sick,  and 
in  the  rarest  cases  it  would  seem  to  be  capable  of  direct  transference 
from  the  sick  to  the  well. 

This  fever  may  be  classed  among  miasmatic  diseases. 


Clinical  History. 

Cerebro-spinal  fever  presents  a  great  diversity  of  symptoms  in  differ- 
ent cases.  Like  other  epidemic  diseases,  its  course  is  attended  by  the 
greatest  variations  in  intensity,  duration,  and  the  prominence  of  particular 
phenomena,  not  only  in  different  epidemics,  but  in  the  same  epidemic. 


CEREBRO-SPINAL   FEVER.  65 

In  this  respect,  however,  it  not  only  resembles  other  epidemic  diseases, 
but  it  also  far  surpasses  them.  No  acute  disease  whatever  appears  in 
such  various  arrays  of  symptoms.  Stille  has  well  called  it  a  "  chameleon- 
like disorder."  It  is  this  that  has  rendered  it  more  difficult  to  describe 
satisfactorily  than  to  recognize  at  the  bedside.  It  is  this  also  that  has 
led  to  the  great  diversity  of  opinions  concerning  it  that  have  been  enter- 
tained by  different  observers. 

It  is  to  this  extraordinary  difference  in  the  symptoms  attendant  upon 
different  cases  and  predominating  in  different  epidemics,  that  are  due  the 
efforts  of  systematic  writers  upon  the  subject  to  simplify  their  descrip- 
tions of  cerebro-spinal  fever  by  the  arrangement  of  the  cases  under  sepa- 
rate groups  or  headings — an  effort  which  in  most  instances  has  failed 
signally  of  its  object. 

Thus,  Forget '  classifies  the  cases  which  came  under  his  observation  at 
Strasbourg  as  follows  : 

A.  Cerebro-spinal  : 

1.  Fulminant. 

2.  Comatose-convulsive. 

3.  Inflammatory. 

4.  Typhoid. 

5.  Neuralgic. 

6.  Hectic. 

7.  Paralytic. 

B.  Cerebral:  * 

1.  Cephalalgia. 

2.  Cephalalgic-delirious. 

3.  Delirious.  » 

4.  Comatose. 

Ames'  and  others  separate  the  cases  into  two  groups: 

1.  The  Congestive. 

2.  The  Erethetic  or  Inflammatory. 

Wunderlich  ^  classifies  the  cases  into  groups  according  to  their  rela- 
tive degree  of  severity,  and  describes — 

1.  The  Gravest. 

2.  The  Less  Grave,  and 

3.  The  Liorhtest. 


'  Gazette  medicale  de  Paris,  1842.  15-20. 

^New  Orleans  Medical  and  Surgical  Journal.     November,  1848. 
^ArchivderHeUkunde.    1864,1805. 
5 


66  THE  CONTINUED   FEVERS. 


Radcliffe  arranges  them  as — 

A. 

Simple. 

B. 

Fulminant. 

C. 

Purpuric. 

Stille 

as — 

A. 

The  Abortive. 

B. 

The  Malignant. 

C. 

The  Nervous. 

a.  The  Ataxic: 

1.  The  Delirious. 

2.  The  Cephalalgic 

3.  The  Neuralgic. 

4.  The  Convulsive. 

5.  The  Paralytic. 

an 

d  h.  The  Adynamic: 

1.  The  Comatose. 

L'.  The  Typhoid. 

D. 

The  Inflammatory. 

E. 

The  Intermittent. 

Bartholow  '  as — 

1.  The  Ordinary  or  Common. 

2.  The  Fulminant. 

3.  The  Petechial.  • 

4.  The  Abortive. 

And  finally  it  has  been  suggested  that  the  cases  may  be  classified  vpith 
reference  to  type  into —  • 

A.  Continued. 

B.  Remittent. 

C.  Intermittent. 

It  is,  I  think,  simpler,  more  convenient,  and  more  in  accordance  with 
modern  methods  of  describing  diseases,  to  adopt  the  plan  followed  by 
German  writers  (Hirsch,  Ziemssen),  and,  shunning  all  artificial  classifica- 
tions, to  give  a  general  sketch  of  the  course  of  the  disease  as  it  appears 
in  the  greater  number  of  cases,  presenting  the  symptoms  as  they  arise, 
group  themselves  and  succeed  each  other,  and  regarding  those  groups  of 
cases  that  differ  broadly  from  this  general  picture,  as  varieties  requiring 
separate  attention  rather  than  as  distinct  forms  of  the  disease. 

In  this  way  will  we  more  readily  keep  in  mind  the  essential  unity  of  the 


'  Practice  of  Medicine.     New  York,  1880. 


CEREBRO-SPINAL    FEVER. 


67 


malady  as  shown  by  its  infectious  character  and  constant  lesions,  under 
tiie  widest  diversity  of  symptoms  in  different  cases. 

The  onset  of  the  disease  is,  in  most  cases,  abrupt.  If  prodromes  occur, 
they  are  of  variable  duration,  and  consist  of  symptoms  referable  to  dis- 
turbance of  the  nervous  system,  such  as  headache,  dragging  muscular 
pains  in  the  neck  and  extremities,  vertigo,  and  a  sense  of  fatigue.  Githens' ' 
statement  that  the  disease  came  on  gradually,  with  usually  "  about  a  week 
of  prodromata,"  is  not  borne  out  by  other  observers.  Ziemssen,  on  careful 
inquiry,  found  prodromes  present  in  only  five  out  of  forty-three  cases. 
When  present,  they  last  from  a  few  hours  to  several  days.  They  are  apt 
to  disappear  shortly  before  the  outbreak  of  the  disease.  In  some  instances 
slight  repeated  shivering  has  preceded  the  attack. 

In  by  far  the  greatest  number  of  cases  the  attack  is  ushered  in  by 
symptoms  of  the  most  formidable  character.  The  patient  is  seized  with  a 
violent  chill;  agonizing  headache,  nausea,  vomiting — which  is  repeated 
and  provoked  by  movement  or  any  attempt  to  rise — supervene.  He  is 
restless,  tossing  about  the  bed  and  oppressed  with  an  overwhelming  sense 
of  illness.  His  countenance  betokens  his  profound  distress.  His  face  is 
seldom  flushed,  usually  pale  or  cyanotic,  sometimes  wearing  the  expression 
of  those  under  the  influence  of  narcotic  poisons.  In  a  short  time  drag- 
ging pains  in  the  neck  come  on,  which  spread  to  a  greater  or  less  extent 
along  the  spine  and  into  the  extremities,  and  are  soon  followed  by  tliat 
tetanic  stiffness  of  the  muscles  of  the  spinal  region  that  is  one  of  the 
characteristic  features  of  the  disease.  Pain  is  now  experienced  in  at- 
tempting to  bend  the  head  forward,  or  to  turn  it  from  side  to  side.  The 
muscular  stiffness  extends  tothe  extremities,  and  movementsare  made  with 
awkwardness  and  difficulty.  In  a  few  hours  or  days  this  symptom  deepens 
into  complete  opisthotonos.  The  head  is  drawn  back,  the  spine  curved, 
the  forearms  flexed  upon  the  arms,  the  legs  upon  the  thighs.  Cramps  in 
the  muscles  of  the  legs  and  elsewhere,  and  spasmodic  twitchings  of  the 
lips,  eyelids,  etc.,  come  and  go.  General  convulsions  may  occur,  especi- 
ally in  children.  With  these  symptoms  of  irritation  of  the  roots  of  motor 
nerves  are  associated  those  of  a  not  less  profound  disturbance  of  sensation. 
Hyperesthesia  of  the  entire  surface  is  present,  but  the  sensitiveness  of 
the  face,  forehead,  and  neck  is  most  marked.  A  slight  pinch,  or  an  at- 
tempt to  separate  the  eyelids  for  the  purpose  of  examining  the  eye,  will 
often  call  forth  an  expression  of  pain,  even  when  insensibility  is  profound. 
The  greatest  suffering  is,  however,  from  the  headache,  Avhich  often  causes 
restlessness  and  expressions  of  suffering  during  insensibility.  It  is  de- 
scribed as  sharp,  lancinating  or  boring,  and  may  be  either  in  the  forehead 


'  Dr.  W.  H.  H.  Githens :  Notes  of  Ninety-eight  Cases  of  Epidemic  Cerebro-spinal 
Meningitis,  treated  in  the  Philadelphia  Hospital.  American  Journal  Medical  Sciences, 
July,  1807. 


68  THE    CONTINUED    FEVERS. 

or  occiput,  or  may  shoot  about  in  all  directions.  Sometimes  it  is  felt  as 
a  constricting  band;  sometimes  it  cannot  be  located,  but  is  spoken  of  as 
an  unutterable  ang-uish.  Pain  of  a  like  nature  is  felt  in  the  lumbar,  epi- 
gastric and  umbilical  regions.  The  abdominal  pain  is  usually  an  early 
symptom,  and  sometimes  precedes  the  vomiting.  Vertigo  persists.  It  re- 
curs upon  every  attempt  to  rise,  and  is  often  distressing  when  the  patient 
lies  quiet,  compelling  him  to  seize  hold  of  the  bed.  The  vomiting  con- 
tinues. At  first  the  contents  of  the  stomach,  afterward  bilious  matters 
and  gastric  mucus,  are  thrown  up. 

The  high  mental  excitement  which  marks  the  onset  of  the  attack 
passes  into  delirium — which  may  be  active,  even  maniacal,  so  that  restraint 
is  required,  or  of  a  busy,  wandering  character.  In  a  short  time  it  passes  into 
somnolence  or  stupor,  which  is,  however,  still  attended  with  more  or  less 
restlessness  and  continual  movement  upon  the  bed.  Various  disturbances 
of  the  special  senses  occur.  Intolerance  of  light  is  constant,  double  vision 
and  temporary  or  even  permanent  blindness,  sometimes  supervene.  Intoler- 
ance of  sounds,  ringing  in  the  ears,  and  dizziness  usher  in  deafness,  which 
is  more  or  less  pronounced  and  not  infrequently  persistent.  Taste  is  lost — 
the  patient  refuses  food;  nevertheless,  the  vomiting  persists.  Constipation 
is  present  at  first,  often  throughout  the  sickness.  Toward  the  end  of  the  at- 
tack, diarrhoea  and  involuntary  discharges  may  take  place.  In  this  respect 
epidemics  differ  greatly,  and  in  truth  it  cannot  be  said  that  the  symptoms 
referable  to  the  alimentar}' canal  are  at  all  characteristic.  The  tongue  is, 
as  a  rule,  lightly  covered  wdth  a  whitish  fur;  where  there  is  great  depres- 
sion it  becomes  dry  and  brown,  and  sordes  collect;  but  this  again  gives 
place  to  a  moist  and  whitish  fur. 

The  fever  is  generally  moderate,  very  irregular,  and  does  not  observe 
a  typical  course.  The  pulse  is  about  normal  in  frequency  or  moderately 
quickened.  It  presents,  however,  the  most  remarkable  variations  in  re- 
spect of  its  frequency,  being  at  one  time  unaccountably  quickened,  at 
another  unaccountably  slowed,  and  these  conditions  succeed  each  other 
with  great  rapidity  and  no  less  irregularity;  the  changes  in  tension  are 
not  less  notable.  The  respirations  are  likewise  irregular.  They  are  at 
first  quickened,  later  they  become  shallow  and  irregular  in  rhythm.  Some- 
times this  irregularity  is  of  that  form  known  as  Cheyne-Stokes  respira- 
tion. 

Cutaneous  eruptions  appear  after  the  first  few  days.  Herpes  is  com- 
mon; erythema,  roseola  and  urticaria  occur.  Petechife  also,  the  sign  of 
blood-disintegration,  are  common.  In  many  epidemics  no  eruption  has 
been  observed.  The  herpetic  eruption  is  most  frequent  on  the  face;  it 
occurs  elsewhere  on  the  body,  and  is  sometimes  symmetrically  distribu- 
ted.    The  others  are  of  irregular  distribution. 

The  disease  develops  rapidly  to  its  height;  from  the  third  to  the  sixth 
day,  the  symptoms  have  reached  their  full  intensity.     If  the  attack  pro- 


CEREBKO-SPINAL    FEVER.  69 

gress  to  an  unfavorable  termination,  the  symptoms  of  motor  and  sensory 
excitation  yield  to  those  of  depression;  the  rigidity  passes  away  and  is 
replaced  by  palsies;  the  stupor  deepens  into  coma;  the  fixed  expression 
of  pain  fades  into  blankness;  the  eyes  are  sunken,  the  pupils  dilated;  no 
noise  disturbs  the  patient.  The  temperature  rises — 40.5°  C.  (105°  F.),  or 
even  42.2°  C.  (108°  F.),  being  attained;  the  pulse  becomes  rapid,  small, 
and 'scarcely  perceptible,  the  breathing  weaker  and  more  shallow,  and,  with 
convulsive  muscular  movements  ending  in  the  most  profound  coma,  death 
puts  an  end  to  the  scene  of  horror. 

If  the  case  run  a  favorable  course,  the  symptomsof  depression  are  less 
marked,  and  they  continue  for  a  much  shorter  time.  Intense  headache, 
backache,  and  muscular  pains  in  the  extremities,  are  complained  of;  the, 
patient  generally  lies  quiet  in  one  position.  There  is  intolerance  of  light 
and  of  sound.  The  vomiting  after  a  few  days,  or  early  in  the  progress  of 
the  case,  comes  to  an  end.  The  headache  and  other  pains  slowly  subside, 
and  with  them  the  muscular  rigidity;  the  strength  is  slowly  regained,  and 
after  a  period  varying  from  two  or  three  to  several  weeks  the  patient  re- 
gains his  health.  The  convalescence  is  often  protracted  for  a  long  time 
by  the  back-  and  head-pains,  and  by  disturbances  of  sight  and  hearing. 

In  certain  instances,  after  the  fever  has  lasted  some  time,  the  patient 
passes  into  that  condition  to  which  the  term  "  typhoid  state  "  has  unfor- 
tunately been  applied,  and  lies  in  a  condition  of  semi-stupor,  with  mutter- 
ing delirium,  a  dry,  cracked  tongue,  sordes  upon  the  teeth  and  gums,  a 
feeble,  rapid  pulse,  involuntary  discharges,  and  like  symptoms  of  vital  de- 
pression. These  are  cases  of  prolonged  meningeal  inflammation  where 
the  infection  has  been  severe  and  the  blood-alterations  profound.  They 
have  been  described  as  the  "typhoid  form"  of  cerebro-spinal  fever  by 
many  writers.  To  classify  these  cases  together  as  a  group,  seems  to  add 
to  the  obscurity  of  the  description  of  the  disease  rather  than  to  simplify 
it.  Certain  cases  of  other  infectious  diseases  tend  to  run  on  into  a  simi- 
lar state.  It  is  profitable  to  regard  them  as  simply  grave  and  protracted 
examples  of  such  affections,  rather  than  to  describe  them  as  separate 
forms.  It  is  above  all  unfortunate  and  unprofitable  to  designate  them  by 
the  term  "  typhoid,"  in  view  of  the  confusion  that  has  existed  as  to  the 
relation  of  cerebro-spinal  fever  to  typhus. 

Cases  occur  in  every  epidemic  that  differ  so  much  from  the  general 
description  of  the  ordinarily  severe  and  mild  forms  of  the  disease,  that 
they  require  separate  consideration  as  varieties.  These  are  the  fulminant, 
the  abortive,  and  the  intermittent  varieties. 

The  fulminant  variety — the  meningitis  cerebro-spinalis  siderans  of 
Hirsch,  and  the  meningite  foudroyante  of  French  writers.  The  poison 
seems  to  fall  upon  the  patient  like  a  thunderbolt.  He  is  struck  down  with- 
out warning,  in  the  midst  of  health,  and  speedily  falls  into  a  state  of  col- 
lapse.    In  a  few  hours  death  may  ensue.     There  is  usually  a  violent  chill; 


k 


70  THE    CONTINUED    FEVERS. 

the  patient  becomes  cyanosed;  the  skin  is  cold — it  may  be  clammy  to 
the  touch,  or  bathed  in  a  profuse  perspiration.  The  face  is  shrunk  and 
livid,  the  eyes  deep-sunk  in  the  orbits.  There  is  shivering-  at  intervals; 
intense  headache  alternates  with  drowsiness,  and,  after  brief  delirium,  un- 
consciousness supervenes.  There  is  contraction  of  the  neck,  and  general 
convulsions  may  usher  in  profound  coma,  which  is  in  most  cases  the  fore- 
runner of  death.  The  respiration  is  slow  and  labored;  the  pulse,  weak  from 
the  onset,  rapidly  grows  more  raj^id  and  more  faint.  The  urine  is  scanty 
and  loaded  with  albumen.  Purpuric  blotches  appear  on  the  surface  of  the 
body  and  pass  quickly  on  to  vesication  and  sloughing.  These  cases  occur 
in  nearly  all  epidemics,  and  with  greatest  frequency  at  the  beginning. 
Some  observers  think  that  they  have  been  less  frequent  in  the  later  epi- 
demics. They  do  not  occur,  as  far  as  is  known,  sporadically.  They  are, 
with  the  rarest  exceptions,  fatal,  death  usually  taking  place  within  a  few 
hours  (five  to  twelve),  though  life  may  be  prolonged  till  the  third  day. 

Tourdes,"  speaking  of  the  suddenness  of  the  attack,  states  that  soldiers 
full  of  youth  and  strength  were  stricken  in  the  street,  at  drill,  in  the  bar- 
racks, whilst  at  meals,  and  succumbed  in  a  few  hours.  Ziemssen  in  43 
cases  encountered  four,  which  proved  fatal  in  12,  24,  28,  and  30  hours  re- 
spectively. 

The  following  case,  abridged  from  the  article  b}'  the  same  author,  will 
serve  as  an  example  of  this  variety  of  the  disease: 

A  child,  aged  eight  years,  was  suddenly  taken  ill,  April  22d,  with  severe  headache 
whilst  at  play,  and  came  home  complaining  and  m  tears.  After  being  put  to  bed  she 
suffered  from  nausea,  active  vomiting,  and  vertigo.  The  headache  increased,  the  eyes 
became  distorted,  the  fingers  of  both  hands  firmly  c'.utclied.  This  condition  is  said  to 
have  lasted  about  two  hours,  during  which  the  patient  remained  apparently  conscious 
and  often  screamed  loudly. 

In  the  evening  she  laid  quietly  in  bed,  perfectly  conscious,  complaining  of  head- 
ache and  intense  thirst ;  her  neck  was  not  stiff  ;  temperature  89.5'  C.  (103.3°  F.),  taken 
in  the  rectum ;  pulse  100.  Late  in  the  evening  there  were  several  attacks  of  vomiting  ; 
she  slept  badly. 

On  the  following  morning  the  headache  was  entirely  gone  ;  the  skin,  especially  that 
of  the  face,  was  very  pale,  moderately  warm  ;  temperature  38.3  C.  (100.7'  F.}  in  the 
rectum  ;  pulse  100. 

Toward  noon  the  patient  felt  better  and  got  up.  She  even  fetched  beer  from  a 
neighboring  public  house. 

About  two  o'clock,  after  having  amused  herself  for  some  time  with  her  sisters.  sh3 
suddenly  became  quiet,  laid  down  upon  the  floor,  and  complained  of  severe  headache. 
In  a  little  while  the  eyes  became  drawn,  marked  contractions  of  the  hands  and  feet 
ensued,  which  were  soon  followed  by  violent  general  convulsions,  with  constant  groan- 
ing and  screaming.  Consciousness  was  said  to  have  been  lost  only  for  a  short  time. 
After  four  hours  the  convulsions  gradually  ceased.  The  child  asked  for  a  drink,  sank 
into  a  stupor,  and  died  in  half  an  hour. 

The  sectio  cadaveric   revealed  a  small  amount  of  sero-puruleut  infiltration  of  the 


'  Histoire  de  I'epidemie  de  meningite  a  Strasbourg  en  1840  et  1841.     Paris,  1843. 


CEEEBRO-SPINAL    FEVER.  71 

arachnoid  and  subarachnoid  spaces  in  the  brain  and  spinal  cord,  anaamia  and  oedema  of 
the  brain  and  spinal  cord,  bronchial  catarrh,  and  partial  collapse  of  the  lungs,  swelling 
of  the  solitary  follicles  of  the  small  and  large  intestines. 

TJie  abortive  variety  occurs  at  the  height  and  during  the  decline  of 
all  epidemics.  Many  cases  do  not  require  confinement  in  bed.  The  pa- 
tients complain  of  headache,  stiffness  in  the  neck  and  spine,  and  malaise. 
Vomiting  occurs,  but  fever  is,  as  a  rule,  absent.  Such  cases  are  instances 
of  the  incomplete  action  of  the  epidemic  influence.  The  diagnosis  rests 
chiefly  upon  the  presence  of  associated  headache,  spinal  stiffness,  and 
vomiting  during  the  prevalence  of  the  epidemic.  All  observers  record 
such  cases.  Stille  narrates  the  case  of  a  girl  who  was  fully  convalescent 
on  the  fifth  day,  and  states  that  he  observed  many  slight  but  distinctly 
marked  cases  that  were  fully  convalescent  within  a  week. 

The  following  examples  of  this  variety  of  the  disease  came  under  the 
observation  of  Dr.  J.  Lewis  Smith: 

"  A  boy  of  eight  years,  previously  well,  was  taken  with  headache,  vomiting,  and 
moderate  febrile  movement,  on  April  20,  1872.  The  evacuations  were  regular,  and  no 
local  cause  of  the  attack  could  be  discovered.  On  the  following  day  the  symptoms 
continued,  except  the  vomiting,  but  he  seemed  somewhat  better.  On  April  4th  the 
febrile  movement  was  more  pronounced,  and  in  the  afternoon  he  was  drowsy  and  had 
a  slight  convulsion.  The  forward  movement  of  the  head  was  apparently  somewhat  re- 
strained. On  the  6th  the  sj'mptoms  had  begun  to  abate,  and  in  about  one  week  from 
the  commencement  of  the  attack  his  health  was  fully  restored." 

"  A  boy,  six  years  old,  was  well  till  the  second  week  in  May,  1872,  when  he  became 
feverish  and  complained  of  headache.  On  May  14th  he  still  had  headache,  with  a  pulse 
of  112.  The  pupils  were  sensitive  to  light,  but  the  right  was  wider  than  the  left.  The 
bromide  and  iodide  of  potassium  were  prescribed,  with  moderate  counter-irritation  be- 
hind the  ears.  The  headache  and  febrile  movement  in  a  few  days  abated,  the  equality 
of  the  pupils  was  restored,  and  within  a  little  more  than  a  week  from  the  first  symp- 
toms he  fully  recovered." 

During  the  prevalence  of  epidemics  of  cerebro-spinal  fever,  some  of 
the  symptoms  characteristic  of  that  disease  have  occasionally  been  ob- 
served as  incidental  complications  of  inflammatory  affections  of  the  lungs, 
pleurse,  and  tonsils.  There  was  chill,  followed  by  headache,  nausea,  and 
vomiting,  and  stiffness  of  the  spinal  muscles;  vertigo,  unconsciousness,  and 
slight  elevation  of  temperature.  In  such  cases  the  symptoms  are  usually 
mild.  It  is  open  to  doubt  whether  or  not  there  be  not,  in  fact,  mild  cases 
of  the  epidemic  disease  complicated  with  local  inflammations.  Two  cases 
cited  by  Ziemssen  would  warrant  the  latter  conclusion. 

Tlie  intermittent  variety  has  been  observed  in  many  epidemics.  The 
intermissions  show  themselves  either  at  the  beginning  of  the  attack,  both 
in  short  and  protracted  cases,  and  at  its  close,  during  the  period  of  conva- 
lescence. They  are  attended  by  complete  or  almost  complete  subsidence 
of  the  fever  and  all  the  other  manifestations  of  the  disease.  The  recur- 
rence of  the  exacerbations  assumes  the  quotidian  or  tertian  type,  but  care- 


72  THE    CONTINUED    FEVERS. 

ful  investigation  has  shown  that  it  lacks  the  regularity  of  true  malarial  dis- 
eases, to  which  the  resemblance  of  these  cases  is  more  apparent  than  real. 
It  has  already  been  shown  that  this  variety  resembles  intermittent  fever 
only  in  the  one  feature  of  alternations  of  periods  of  activity  of  the  symp- 
toms and  periods  of  repose.  The  intermittent  course  of  the  disease  often 
lasts  for  several  weeks  and  finally  suddenly  ends  in  the  death  or  recovery 
of  the  patient.  At  other  times  the  prodromal  stage  consists  of  several 
brief  attacks,  and  again  the  convalescence  may  be  broken  by  a  series  of 
severe  paroxysmal  seizures,  led  in  by  chills  and  attended  by  fever  of  a  high 
grade— 40°  C.  (104°  F.). 

The  following  case  serves  at  the  same  time  as  an  illustration  of  the 
mildest  form  of  cerebro-spinal  fever  and  of  its  intermittent  variety.  It 
occurred  under  Dr.  J.  Lewis  Smith's  care. 

"  A  girl  of  thirteen  was  seized  in  the  last  week  of  December,  1872,  with  vomiting, 
followed  by  headache.  Duricg  a  period  of  from  six  to  eight  weeks,  or  tiU  nearly  the 
first  of  March,  she  presented  the  following  symptoms :  daily  paroxysmal  headache, 
often  most  severe  in  the  forenoon,  neuralgic  pain  in  the  left  hypochondrium  and  some- 
times in  the  epigastric  region ;  pulse  and  temperature  sometimes  nearly  normal,  at 
others  accelerated  and  elevated,  both  with  daUy  vomiting ;  inequality  of  the  pupils,  the 
right  being  larger  than  the  left  during  a  portion  of  the  sickness.  This  patient  was 
never  so  ill  as  to  keep  the  bed.  usually  sitting  quietly  during  the  day  in  a  chair,  or  re- 
clining on  a  lounge,  and  she  never  fully  lost  her  appetite.  Quinine  had  no  appreciable 
effect  on  the  paroxysms  of  pain  or  fever." 

Analysis  of  the  Symptoms, 
symptoms  pebtaining  to  the  nervous  system. 

A  chill  of  more  or  less  decided  character,  often  very  severe  and  some- 
times lasting  from  one  to  two  hours — less  frequently  a  shivering,  which 
speedily  passes  over — marks  the  onset  of  the  attack.  This  phenomenon  is 
occasionally  repeated  several  times  in  the  course  of  the  first  day. 

The  attack  begins  most  frequently  in  the  evening,  during  the  night  or 
on  rising,  less  commonl}^  during  the  early  hours  of  the  day.  The  patient 
in  some  instances,  having  gone  to  bed  in  perfect  health,  awakes  with  symp- 
toms of  the  most  alarming  kind.  During  the  subsidence  of  epidemics,  the 
beginning  of  the  sickness  is  less  apt  to  be  abrupt.  It  is  also,  as  a  rule,  of 
more  gradual  approach  in  children. 

Headache  is  among  the  earlier,  the  more  distressing,  constant  and 
more  persistent  symptoms  of  the  disease.  It  is  absent  only  in  those  cases 
of  the  fulminant  variety  in  which  the  patient  is  overcome  as  by  a  light- 
ning-stroke, and  falls  directly  into  collapse.  The  seat  of  the  pain,  as 
has  already  been  pointed  out,  is  variable.  Its  agonizing  character  is  al- 
most constant.  The  patient  is  thrown  by  it  into  the  greatest  restlessness. 
He  throws  his  arms  about  frantically,  or,  pressing  his  hands  against   his 


CEREBRO-SPINAL    FEVER.  73 

head,  groans  and  cries  in  agony.  Even  in  deep  stupor  or  in  coma  he 
oives  expression  to  this  pain  by  moving  his  hands  to  liis  head  and  by  fre- 
quent groaning.  Headache  usually  continues  throughout  the  attack,  with 
slio-ht  daily  variations;  in  many  instances  it  shows  marked  remissions  and 
sometimes  distinct  intermissions.  Its  cessation  during  the  attack  is  a 
most  favorable  indication.  In  many  cases  the  liability  to  headache  of  a 
severe  kind  continues  for  years  after  the  attack  of  cerebro-spinal  fever, 
being  excited  by  unusual  bodily  or  mental  exertion  and  like  depressing 
causes. 

The  seat  of  the  headache  does  not  necessarily  indicate  the  position  of 
the  inflammatory  products  found  after  death,  nor  the  points  of  most  in- 
tense meningeal  inflammation;  nor  does  its  violence  correspond  to  the  in- 
tensity or  danger  of  the  disease.  It  is  not,  therefore,  a  symptom  of  great 
prognostic  value,  seeing  that  it  is  most  intense  in  many  favorable  cases, 
and  absent  in  some  that  lead  to  a  fatal  issue  in  the  course  of  a  few  hours. 
Vertigo  is  also  an  early  symptom,  sometimes  appearing  as  a  prodrome. 
Associated  with  the  headache,  it  adds  not  a  little  to  the  distress  of  the 
patient.  Suddenly  seized  by  it,  patients  have  staggered  like  drunken 
men;  others  have  fallen,  unable  to  rise  again.  It  is  occasionally,  even  in 
the  recumbent  posture,  troublesome. 

The  recurrence  of  vertigo  and  headache  during  the  convalescence, 
after  they  have  entirely  ceased,  is  to  be  regarded  with  anxiety.  It  often, 
especially  when  associated  with  vomiting  and  convulsions,  betokens  the 
development  of  hydrocephalus. 

Vomiting  is  to  be  regarded  as  a  symptom  referable  to  the  disturb- 
ance of  the  nervous  system.  It  is  an  initial  symptom,  often  occurring 
without  any  previous  nausea,  and  lasting  one  or  two  days.  It  is  pro- 
voked by  movements,  and  in  particular  by  rising.  It  recurs,  in  some 
cases,  with  frequency  throughout  the  sickness,  and  adds  to  the  depres- 
sion by  interfering  with  the  assimilation  of  food. 

Hallucinations  and  delirium,  though  much  less  constant  and  persis- 
tent than  headache,  are  present  in  almost  all  the  severe  cases.  They 
occasionally  occur  early  in  the  attack,  more  commonly  not  until  the 
second  or  third  day.  The  delirium  varies  greatly  in  degree  and  kind. 
It  appears  in  some  cases  to  be  the  direct  result  of  the  violence  of  the 
headache.  It  is  often  transient  and  seldom  continuous  throughout  the 
course  of  the  attack,  longer  or  shorter  periods  of  lucidity  commonly  in- 
tervening between  the  outbreaks,  or  else  the  delirium  alternates  with 
periods  of  somnolence  or  stupor.  It  is  not  seldom  of  a  furious  kind,  the 
patients  falling  into  a  state  of  frantic  excitement,  and  being  restrained 
with  difficulty.  Such  violent  manifestations  may  alternate  with  periods 
of  placidity.  Sometimes  the  sick  lie  in  a  quiet,  wandering  state,  from 
which  they  may  be  aroused  so  as  to  make  intelligible  replies.  Again  it 
may  resemble  intoxication  or  hysteria.     I  conducted  t\\Q  post-mortem  ex- 


74  THE    CONTINUED    FEVERS. 

amination  of  the  body  of  a  young  married  woman,  who  died  during  the 
epidemic  of  1873  in  Philadelphia,  of  cerebro-spinal  fever,  with  obscure 
symptoms  and  a  delirium  resembling  hysteria.  The  mental  state  of 
many  patients  ma}'  be  expressed  by  such  terms  as  apathy  or  indifference. 
In  fatal  cases  the  delirium  passes  into  the  coma  which  precedes  death.  In 
mild  cases  there  may  be  slight,  transient  delirium,  occurring  often  only  at 
night,  or  hallucinations  upon  particular  subjects — a  form  of  monomania. 

Restlessness,  though  less  frequent  than  the  foregoing  conditions,  is  not 
uncommonly  present,  especially  early  in  the  progress  of  the  case.  The 
patient  tosses  about  in  the  bed  and  keeps  his  arms  and  legs  in  constant 
movement,  or  he  seeks  to  spring  from  the  bed,  and  has  to  be  restrained 
by  force. 

Sleejilessness  is  present  in  a  considerable  number  of  cases,  and  is  often 
met  with  in  the  history  of  the  stage  of  the  j^rodromes.  Hirsch  regards 
this  condition  as  so  constant  at  the  height  of  the  disease,  that  "  if  one 
find  a  patient  who  has  suffered  from  it  apparently  sleeping,  he  may  be  al- 
most sure  that  he  has  fallen  into  a  stupor."  In  such  cases  the  occurrence 
of  a  long,  quiet  sleep  is  to  be  regarded  as  an  exceedingly  favorable  change 
in  the  course  of  the  disease. 

Coma,  as  has  been  incidentally  pointed  out,  occurs  in  by  far  the  great- 
est number  of  fatal  cases,  and  is  generally  the  forerunner  of  death.  It 
may  occur  in  the  graver  and  in  rapidly  fatal  cases  without  the  interven- 
tion of  delirium. 

Stiffness  or  contraction  of  the  neck  is  an  almost  constant  and  ver\' 
characteristic  symptom.  It  is  rarely  seen  on  the  first  day,  and  is  then 
only  slightly  manifest.  It  becomes  marked  between  the  second  and  fifth 
days,  and  may  continue,  in  cases  terminating  favorably,  from  three  to  five 
weeks,  or  even  far  into  the  convalescence,  relaxing  gradually.  It  varies 
greatly  in  degree  from  a  slight  stiffness,  not  easily  perceived,  but  becom- 
ing apparent  upon  attempting  to  bend  the  head  forward,  to  a  contraction 
so  great  that  the  back  of  the  head  is  held  firmly  between  the  shoulders,  at 
almost  a  right  angle  with  the  spine.  In  the  latter  case  swallowing  is  per- 
formed with  difficulty,  and  active  or  passive  attempts  to  bend  the  head 
forward  are  alike  futile,  partly  by  reason  of  the  rigid,  tetanoid  charac- 
ter of  the  contractions,  partly  because  of  the  great  pain  to  which  they 
give  rise.  The  degree  of  contraction  is  by  no  means  always  proportion- 
ate to  the  neck-pain.  On  the  contrary,  this  pain  is  sometimes  absent  as 
the  patient  lies  at  rest,  and  is  called  forth  only  upon  efforts  to  overcome 
the  contraction. 

Contraction  of  the  other  erector  ^nuscles  of  the  sjnne  is  also  very  often 
present.  This  leads  to  a  straightening  of  the  spine  (orthctonos),  with 
stiffness  and  the  prominence  of  the  contracted  muscular  masses  and  the 
disappearance  of  the  spinous  processes  between  them,  or  more  rarely,  in  its 
highest  grade,  to  complete  tetanoid  opisthotonos.     It  adds  not  a  little  to 


CEREBRO-SPINAL    FEVER. 


li> 


the  discomfort  of  the  suiferer,  who  is  debarred  from  lying  upon  his  back, 
and  turns  from  one  side  to  tlie  other  with  the  utmost  pain  and  difficulty. 

The  duration  of  this,  as  of  most  of  the  symptoms  of  cerebro-spinal 
fever,  is  very  variable.  Sometimes  it  lasts  only  a  few  days,  at  others 
weeks,  and  patients  have  been  confined  to  bed  by  it  till  the  fourth  and 
even  the  sixth  week  from  the  beginning-  of  the  attack.  Ziemssen  states 
that  he  has  seen  convalescents  going  about  with  rigid  spines. 

Pleurosthotonos,  or  contraction  of  the  spinal  muscles  of  one  side,  has 
been  encountered  by  some  observers.  Levy  saw  it  twice  in  tifty-seveu 
cases.     It  is  extremely  rare. 

The  stilfness  of  the  neck  is  sometimes  absent.  This  observation  has 
been  made  in  some  instances  where  the  ordinary  anatomical  changes,  and 
particularly  the  inflammation  and  exudation,  have  been  present  in  the 
spinal  meninges  to  an  extent  as  great  as  that  usually  met  with.  Its  ab- 
sence cannot  be  explained. 

Trismus  has  been  observed  only  in  patients  who  were  extremely 
ill  and  comatose.  It  is  highly  ominous.  Of  five  cases  encountered  by 
Hirsch,  four  speedily  perished. 

Stiffness  and  contraction  of  the  muscles  of  the  extremities  occur  in  a 
considerable  proportion  of  the  cases.  Active  movements  are  executed  in 
such  instances  with  awkwardness  and  pain,  and  passive  movements  are 


Fig.  3.— Attitude  of  Child  in  severe  Cerebro-spinal  Fever.     (J.  Lewis  Smith.) 

resisted.  The  usual  position  of  such  patients,  in  bed,  is  with  the  head 
drawn  back,  the  forearms  flexed  upon  the  arms,  and  the  knees  drawn  up 
upon  the  abdomen,  with  or  without  forward  arching  of  the  spine  (Fig.  3). 
Clonic  sjKisms  or  convulsions  occur  with  less  frequency  than  muscular 
rigidities.  They  are  met  with,  however,  in  a  considerable  proportion  of 
the  cases,  particularly  in  children,  with  whom  they  sometimes  occur  as  an 
earh^  symptona,  replacing  the  initial  chill.  General  convulsions  have  been 
observed  to  usher  in,  the  attack  in  adults  also,  but  much  more  rarely. 
They  vary  in  degree  from  twitchings  of  single  muscles  or  groups  of  mus- 
cles, to  violent  epileptiform  seizures  attended  with  loss  of  consciousness; 
the  latter  constitutes  in  adults  a  symptom  of  great  gravity. 


76  THE    CONTINUED    FEVERS.  ' 

Tremors  and  subsultus  tendinum  are  less  frequently  observed. 

l^arahjsis  is  of  much  less  common  occurrence  than  the  character  of 
the  lesions  would  lead  us  to  expect.  It  occurs  in  a  small  proportion  of 
the  cases,  and  affects  one  or  both  extremities,  upper  or  lower,  and  may  be 
more  or  less  complete.  Hemiplegia  may  also  occur.  Palsies  of  certain 
associated  groups  of  muscles,  as  those  of  deglutition,  articulation,  and 
others,  are  relatively  more  common.  Paralysis  is  very  rare  as  an  early 
symptom;  it  appears  toward  the  close  of  the  disease.  If  the  patient  re- 
cover, it  usually  passes  away  in  the  course  of  a  few  days  or  weeks;  ex- 
ceptionally it  is  of  long  persistence,  or  even  permanent.  More  or  less 
complete  general  paralysis  is  encountered  as  one  of  the  phenomena  of 
approaching  dissolution. 

The  facial  expression  is  indicative  of  the  severe  pain  which  attends 
the  disease.  The  features  wear  a  fixed  and  rigid  look,  which  passes  with 
the  exhaustion  into  an  expression  of  apathy,  without  relaxing  into  the 
■flushed  dulness  of  typhus,  nor  the  languid  expression  of  enteric  fever. 
The  face  is  usually  pale. 

Pain  in  the  spine  (rachialgia),  and  especially  in  the  neck,  is  a  fre- 
quent symptom.  It  varies  greatly  in  extent  and  intensity,  as  well  as 
in  duration.  It  appears  sometimes  coincidently  with  the  headache,  and 
has  been  observed  as  an  occasional  symptom  late  in  convalescence.  A 
dragging  pain  in  the  neck  has  already  been  mentioned  as  one  of  the  pro- 
dromes. This  pain,  like  the  headache,  is  subject  to  remissions  and  exacer- 
bations. 

Severe  pains  in  the  extremities,  especially  in  the  legs,  also  frequently 
occur.  They  are  often  evoked  or  intensified  by  movements  of  the  spine. 
Lightning-like  pains  invade  other  parts  of  the  body,  and  an  intense  sick- 
ening neuralgic  pain  in  the  abdomen,  particularly  in  the  epigastric  and 
umbilical  regions,  is  very  common.  This  pain  is  sometimes  associated 
with  uncontrollable  vomiting.  It  was  so  common  a  symptom  in  the  epi- 
demic observed  by  Dr.  Sanderson  in  the  Lower  Vistula,  that,  as  he  in- 
forms us,  the  disease  acquired  among  the  people  the  trivial  designation 
of  "The  Belly-Ache." 

Pain  of  a  similar  nature  is  sometimes  referred  to  the  chest,  and  at 
times  is  associated  with  difficulty  in  breathing.  Asthmatic  attacks  are 
spoken  of  as  occurring  in  some  cases.  It  is  probable,  from  their  rarity,  that 
they  are  incidental  symptoms. 

Hyperaisthesia  of  the  skin,  the  joints,  and  other  soft  parts,  though  far 
from  being  a  constant  symptom,  is  to  be  regarded  as  characteristic  when 
it  does  occur,  and  as  sharply  drawing  the  boundary  line  between  this  and 
any  other  disease  with  which  it  can  possibly  be  cor^founded.  It  is  absent 
altogether  in  many  cases  and  in  some  epidemics;  in  others  it  is  a  very 
common  symptom,  and  was  frequently  observed  in  the  later  epidemics  in 
the  United  States,  and  in  that  of  the  Lower  Vistula  in  18G5.     It  occurs 


CEREBKO-SPLN-AL    FEVER. 


77 


early  in  the  course  of  the  attack,  often  on  the  second  or  third  day,  and  is 
often  so  extreme  as  to  cause  great  additional  suffering,  the  patient  lying 
as  quietly  in  the  bed  as  the  restlessness  so  common  in  the  affection  will 
permit,  in  order  to  avoid  this  pain,  which  a  movement  of  his  limbs,  a  light 
touch  upon  the  surface  of  his  body,  even  the  shaking  of  the  bed,  will 
evoke. 

It  is  a  symptom  which  often,  when  present,  interferes  greatly  with  the 
examination  of  the  sick.  Its  commonest  seat  is  the  anterior  surface  of 
the  body,  especially  of  the  legs  and  thighs,  though  it  is  everywhere 
present.    It  is  often  associated  with  marked  intolerance  of  light  and  sound. 

Ancesthesia  of  portions  of  the  surface  in  some  instances  follows  the 
symptom  just  described.  Stille  observed  it  in  many  cases  during  the  epi- 
demic which  is  recorded  in  his  writings.  It  is  sometimes  marked,  some- 
times a  mere  numbness.  It  disappears,  as  a  rule,  during  the  progress  of 
the  case. 

SYMPTOMS  BEFERABLE  TO  THE  SKIN. 

Many  observers  state  that  the  skin  is  apt  to  be  dry  in  the  early  days, 
of  the  disease,  and  afterward  bathed  in  moisture,  especially  the  head,  face, 
and  neck.  But  in  this  respect  cases  furnish  no  constant  condition.  The 
pallor  and  cyanosed  appearance  of  the  surface,  especially  of  the  face, 
which  is  uniformly  present,  has  been  already  more  than  once  alluded  to 
in  the  description  of  the  disease. 

Cutaneous  lesions  are  very  common  and  constitute  a  group  of  phenom- 
ena of  great  interest  in  the  study  of  this  affection.  In  some  epidemics, 
they  are  present  in  by  far  the  greatest  number  of  the  cases,  while  in  others 
no  eruption  whatever  can  be  discovered  in  most  of  the  instances  of  the 
disease.  Were  this  statement  not  correct,  it  would  be  impossible  to  recon- 
cile the  conflicting  accounts  of  many  competent  observers. 

Ziemssen  remarks  that  it  would  be  difficult  to  understand  from  obser- 
vations of  the  German  epidemics  why  the  disease  has  been  called  "  spotted 
fever  "  by  American  physicians.  Many  recorded  observations  of  epidemics, 
in  the  United  States,  however,  go  to  show  that  in  not  infrequent  in- 
stances eruptions  are  altogether  absent,  or  present  in  but  a  small  number 
of  the  cases.  There  can  be  no  doubt  that  roseola  and  petechiae  are  more 
common  in  cerebro-spinal  fever  in  this  country  than  in  Europe. 

Herpes  is  the  most  common  of  the  eruptions.  It  is  usually  confined 
to  the  face  (her^Jes  facialis),  but  may  appear  upon  the  trunk  as  shingles- 
{herpes  zoster),  or  in  circumscribed  patches  upon  the  extremities.  It  be- 
gins generally  in  the  region  of  the  mouth,  upon  the  upper  or  lower  lip^ 
and  extends  to  the  nose,  cheeks,  ears,  and  eyelids.  In  many  cases  one  or 
both  sides  of  the  face  are  covered  with  a  hideous  mass  of  herpetic  vesi- 
cles or  crusts.     This  eruption  is  also  met  with  on  the  mucous  surface  of 


78  THE    CONTINUED    FEVERS. 

tlie  nostril  and  cheek,  and  upon  the  scalp.  It  is  in  many  cases  an  early 
symptom,  appearing  on  the  second  or  third  day ;  but  irregular  outbreaks 
of  vesicles  often  take  place  late  in  the  convalescence.  No  prognostic 
significance  can  be  ascribed  to  it. 

Petechioe  occur  in  the  next  order  of  frequency.  The  mottling  is 
more  or  less  distinct  and  widely  dilfused  over  the  surface,  sometimes  even 
involving  the  face.  Larger  spots  of  like  character  resembling  the  erup- 
tion of  purpura  are  likewise  common.  Wide  effusions  of  blood  and  its 
coloring  matter  beneath  the  skin  (vibices,  ecchymoses)  also  occur.  They 
have  sometimes  a  regular,  sometimes  an  irregular  or  ragged  edge  or 
border,  which  may  remain  fixed  from  the  time  of  its  appearance,  or  may 
extend  rapidly  over  large  surfaces.  They  are  sometimes  light  or  bright  red 
in  the  beginning,  and  grow  dark  or  livid  in  the  lapse  of  a  short  time;  of- 
tener,  however,  they  are  dark  purple  or  black  from  the  first,  and  have  been 
likened  to  splashes  of  ink.  They  often  resemble  the  livid  staining  of  the 
skin  in  the  cadaver.  These  extensive  effusions  of  the  coloring  matter  of 
the  blood  are  of  ominous  significance  as  betokening  the  gravest  disintegra- 
tion of  its  corpuscular  elements. 

Dr.  J.  Lewis  Smith  has  observed  that  the  size  and  position  of  such 
spots  is  sometimes  determined  by  bruises  which  the  patient  receives  dur- 
ing his  spells  of  restlessness.  The  purpuric  spots  are  sometimes  hard 
to  the  touch,  with  defined  margins.  Vesicles  may  form  and  superficial 
gangrene  of  the  skin  take  place,  which,  if  recovery  follows,  gives  rise  to 
permanent  scarring.  A  cyanosed  appearance  of  the  surface  and  livid 
mottlings  may  also  occur  without  distinct  eruption. 

Less  frequent  are  roseola,  erythema,  urticaria,  erysipelas,  and  suda- 
onina.  Not  infrequently  a  patient  presents  three  or  four  separate  forms 
of  cutaneous  eruptions. 

The  symmetrical  distribution  of  the  eruptions  of  cerebro-spinal  fever 
have  often  been  made  the  subject  of  remark.  It  is  not  uncommon  to  find 
similar  eruptions  and  patches  of  eruption  seated  in  the  same  position, 
upon  both  sides  of  the  body  or  on  the  two  extremities.  This,  together  with 
the  variety  of  the  forms,  their  frequency  and  the  hypera?sthesia  and  ances- 
thesia,  point  to  disturbance  of  innervation  in  the  central  nervous  system 
directly  affecting  nutrition  (disturbances  of  trophic  innervation).  The 
purpuric  eruptions  are  chiefly  due  to  the  breaking  up  of  the  red  blood-cor- 
puscles, and  the  solution  of  their  coloring  matter  in  the  serum  ;  and  per- 
haps in  part,  to  other  causes  not  yet  known. 

THE  PHENOMENA   OF   THE   FEVEB. 

The  temperature  during  the  course  of  the  disease  does  not  give  rise, 
when  depicted  in  the  graphic  method,  to  a  typical  curve. 

It  is  above  the  normal  in  every  case,  except  perhaps  those  of  the  ful- 


CEKEBRO-SPINAL    FEVER.  79 

ininant  variety,  in  which  the  patient  falls  speedily  into  a  state  of  collapse. 
It  is  generally  moderately  high,  not  always  on  the  first  day,  but  from  the 
second  or  third  day.  In  some  instances  it  rises  rapidly  after  the  chill, 
which  mai'ks  the  onset  of  the  attack.  After  the  characteristic  symptoms 
of  the  disease  are  fully  established,  the  temperature  rarely  falls  below 
37.5°  C.  (99.5°  F.),  and  ranges  in  adults  from  38°  C.  (100.4°  F.)  to  40°  C. 
(104°  F.)  for  average  cases.  In  children  it  is  frequently  higher.  J.  Lewis 
Smith  has  recorded  a  temperature  (rectal)  of  nearly  42°  C.  (107.4°  F,),  a 
few  hours  after  the  onset  of  the  attack,  in  a  young  child  who  died  on  the 
third  day,  and  in  two  other  instances  a  temperature  of  over  41°  C.  (106° 
F.).  Both  of  these  cases  also  terminated  in  death,  one  on  the  ninth  day, 
the  other  in  the  ninth  week.  In  severe  cases  it  is  apt  to  be  high,  and  in 
particular,  it  rises  as  death  approaches.  Periods  marked  by  long-con- 
tinued subfebrile  temperatures  of  ten  occur  in  the  course  of  an  attack,  and 
very  irregular  variations,  both  below  and  above  the  average  range,  are 
common.  During  such  periods  of  relatively  low  temperature  the  other 
symptoms  remain  unabated.  There  is  no  constant  and  notable  difference 
between  the  morning  and  evening,  as  in  typhoid  and  typhus.  A  gradual 
fall  (lysis)  marks  the  beginning  of  convalescence  ;  an  abrupt  fall  ushers 
in  collapse  or  death.  A  critical  fall  in  temperature  does  not  occur  to  sig- 
nalize the  favorable  termination  of  this  disease. 

"VVunderlich  '  concluded,  from  a  study  of  thirty  cases,  that  three  vari- 
eties of  the  fever  course  may  be  distinguished  : 

"  (a)  In  some  very  severe  and  rapidly  fatal  cases  the  temperature, 
though  not  invariably  very  high  at  the  beginning  of  the  disease,  reaches 
very  striking  heights  in  the  briefest  time.  It  remains  high,  rising  even 
higher  at  the  approach  of  death,  till  in  the  very  moment  of  death  it  may 
attain  42°  C.  (107.6°  F.),  and  more.  In  one  of  his  cases  it  reached  43.7° 
C.  (110.7°  F.).  It  may  rise  some  tenths  of  a  degree  after  death.  In  the 
case  just  cited,  it  was  44.1°  C.  (111.5°  F.),  three-quarters  of  an  hour  after 
death.  There  were  also  some  fatal  cases  in  which  the  temperature  for 
some  time  was  very  moderate,  and  rose  rapidly  with  abruptness  at  the 
close  of  life. 

"  (b)  On  the  other  hand,  relatively  mild  cases  exhibit  a  fever  of  only 
short  duration,  although  there  are  sometimes  considerable  elevations  of 
temperature  and  often  an  interrupted  course.  Recovery  does  not  take 
place  by  crisis,  but  happens  rather  with  a  remittent  defervescence  (lysis). 
Here  and  there  cases  occur  which,  after  defervescing  and  apparently  al- 
most recovering,  relapse  all  at  once  with  a  rapid  rise  of  temperature  and 
run  a  course  like  the  cases  marked  (a). 

"  (c)  In  contrast  with  these  brief  courses  of  fever  with  either  very 
severe  or  slight  character,  we  find  cases  which  are  more  or  less  protracted. 

'  The  Temperature  in  Diseases.  Trans,  of  New  Sydenham  Society.   London,  1871. 


80 


THE    CONTINUED    FEVEKS. 


The  height  of  the  temperature  in  these  may  be  varied,  and  indeed  may  ex- 
hibit manifold  changes  in  the  very  same  case,  though  tiiis  chieily  depends 


Temperature. 

Day  of  the      I.        II.       III.       IV. 
Disease.    — '^ —  —  '  —  — ■'  —  — 


40°  10-4.° 


V.       VI. 


Pulse. 
III.       IV. 


VI. 


100.4= 


%.S° 


,  K  |M|E  |ill  E,JI;E  I  M,  E  lil.  E  I  M    E    .M    i;     .M    1,     .M     i;    M    E  , -U  ,  E 

Fig.  4. — Temperature  Ilange  aud  Pulse  in  Cerebro  siiinal  Fever,  Severe  Form. 


Day  of  the 

Disease. 
C.    I     F. 


VII.   VIII.     IX.      X.       XI.     XII.    XIII.   XIV.     XV.    XVI. 


09.5° 

;)8.(;° 

160 
150 
1-40 

130 
120 
110 
100 
90 
81 


E    .M 
Fig.  5, 


E    JI :  E  !  M  ,  E  I  M  i  E  I  -M ,  E  ]  m"  E  I  M  1  E  i  JI  ,  E    -^1 ,  E    M  ,  E  ,  M  ,  E    .M ,  E  ,  M  ;  E  |  il  |  E  ,  M  j  E 
.—Temperature  Range  and  Pulse  in  Cerebro-spmal  Fever,  Moderately  Severe  Form. 


upon  the  varied  complications  which  supervene  in  the  shape  of  bronchial, 
})ulnionary  and  intestinal  affections,  and  affections  of  serous  membranes." 


CEREBRO-SPINAL    Jb'EVEK.  81 

Githcns  made  records  of  the  temperature  in  forty-four  of  his  ninety- 
ei<»'lit  cases,  with  the  following  results.  "In  two  cases  only  did  the  ther- 
niometer  in  the  axilla  reach  105°.  In  fifteen  cases  it  was  between  104° 
and  105°;  in  twelve  between  103°  and  104°;  in  seven  between  102°  and 
103°;  ]n  six  between  101°  and  102°,  and  in  two  it  was  below  100°.  The 
figures  given  are  the  highest  points  reached  in  each  case.  The  difference 
in  the  temperature  at  the  evening  and  morning  observations  was  not  so 
marked  as  in  most  other  fevers — a  fall  of  more  than  one  degree  being  un- 
usual, and  frequently  there  was  no  change.  A  regular  and  gradual  de- 
scent indicated  the  beginning  of  convalescence  ;  a  rapid  fall  was  the  sure 
precursor  of  collapse." 

Sanderson  found  that  exacerbations  of  pain  were  always  accompanied 
))y  a  rise  in  temperature  of  from  two  to  three  degrees  Fahrenheit. 

One  of  the  more  notable  characters  of  the  febrile  phenomena  of  this 
malady  is  their  extreme  irregularity.  The  temperature  ranges  not  only 
do  not  coincide,  they  also  do  not  even  approach  an  ideal  type. 

Finally,  I  transcribe  from  the  pages  of  Ziemssen  diagrams  illustrat- 
ing the  curves  of  the  temperature  and  pulse  in  severe,  mild,  and  the  so- 
called  intermitting  cases.  They  are  accompanied  with  brief  abstracts  of 
the  clinical  notes  of  the  cases: 

Case  I. — Severe  form. — "  L.  W.,  aged  fifteen  years,  a  plasterer's  apprentice.  Ac- 
cess abrupt,  with  chills,  cephalalgia,  vomiting,  trismus,  tetanus  of  cervical  and  spinal 
muscles.  Conjunctivitis,  hyperae.sthesia  of  skin.  After  the  fourth  day,  herpes 
facialis,  roseola,  erythema,  urticaria,  and  petechias  on  the  extremities.  Moderate 
fever,  with  retardation  of  imlse.  Furious  delirium  followed  by  sopor.  With  rapid 
elevation  of  temperature  and  pulse,  death  ensued  on  the  seventh  day  of  the  disease. 

Autoj)i^y. — Purulent  cerebro-spinal  meningitis.  Remains  of  old  pleurisy  and  peri- 
hepatitis. Partial  atelectasis  of  lungs,  and  lobular  pneumonia.  Cadaverous  softening 
of  stomach  and  diaphragm  (five  hours  after  death).  Suppurative  tendo-synovitis  in 
the  left  hand.  Areas  of  degeneration  in  the  spinal  and  recti  abdominis  muscles. 
Ulceration  of  cornea ''  (Fig.  4,  p.  80). 

Case  II. — Modcnitely  severe  foi-m. — '' M.  V.,  aged  twelve  years,  daughter  of  a 
stocking-weaver.  Access  abrupt,  with  chill  and  vomiting,  which  lasted  during  the  first 
four  days.  Frontal  headache.  Stiffness  and  pain  in  the  spine,  jactitation,  urgent 
thirst.  Mind  at  first  clear,  afterward  delirium  and  somnolence.  Petechia}  on  the 
second  day,  herpes  on  the  face  on  the  seventh,  on  the  thumb  on  the  tenth  day.  Effu- 
sion into  the  right  wrist-joint.  Conjunctivitis  and  keratitis.  Aphthae.  Temperature 
at  first  high,  but  gradually  diminishing,  while  pulse  became  very  rapid.  Tedious  con- 
valescence.    Duration  of  the  disease  about  six  weeks  "  (Fig.  5,  p.  80). 

Case  III. — Mild  form. — "  C.  H.,  aged  ten  years,  daughter  of  an  umbrella-maker. 
After  a  prodromal  stage  of  two  days'  duration,  patient  was  taken  ill  with  pains  in  the 
head,  extremities  and  epigastrium,  nausea,  vomiting,  stiffness  of  neck,  delirium, 
premature  menstruation  ;  herpes  on  the  fourth  day,  conjunctivitis,  and  transient 
fever.  Improvement  at  the  end  of  the  first  week.  Duration  of  the  disease,  three 
weeks  "  (Fig.  6). 

Case  W .—Intermittent  form. — "  Th.  M.,  aged  nineteen  years,  student.  Prodro- 
niata  for  eight  days.  Access  abrupt,  with  cephalalgia,  vomiting,  slight  convulsions, 
f> 


82 


TJIE    CONTINUKIJ    FEVEKS. 


unconsciousness.  Neck  somewhat  stiff.  No  fever  during  the  first  few  days.  Exacer- 
bation on  the  fourth  day,  with  fever  of  short  duration,  followed  by  apyrexia  and  dis- 
appearance of  the  malaise.  On  the  fifth,  seventh,  and  eighth  days,  the  exacerbations 
recurred  with  marked  spinal  symptoms.  Then  followed  daily  exacerbations,  but  of 
less  intensity  and  shorter  duration.  No  eruption.  Complete  cessation  of  febrile 
attacks  after  the  eighteenth  day.  Recovery.  Duration  of  disease  six  weeks ;  of  con- 
valescence, four  weeks"  (Fig.  7). 

In  these  cases  the  thermometer  by  no  means  shows  the  regularity  that 
characterizes  malarial  fevers,  or  that  a  superficial  study  of  the  symptoms 


36°    96  8° 


ToiuiJcraLuie.  I'lilsc. 

II.      III.    IV.       V.      VI.      VII.  VIII.      II.     III.      IV.       V.      VI.     VIL   VIII. 


E|M|E|M|E|M|E|M|E|MlE|iM|E|M         |E|M|E|M|E|M|E|M|B|M|E|M|E 
Fig.  6. — Temperature  Range  and  Pulse  in  Cerebro-epinal  Fever,  Mild  Form. 


n.     ni.    IV. 


VI.    VII.   VIII.     IX. 


41°  105.h' 
40°  1G4° 
39°  102.2' 
38° 
37°  I  98.(i° 
36°'  96. 8f 


XI.    xu.  xm.  XIV.  XV.  XVI.  xvii.xviii.xrx. 

!■■■■■■■■ 

!■■■■■■■■ 


. -JWHnw^i«iBB!!!BSSBgK«gBBB£>!!!uiB, 


SSS[ 


!!■■■■■■■■■■■■■■■■■■■■ 


M|EiM|BiM|E|M|ElM|B|M|E|M|ElM|E|M|E|M|ElMlB|M|E|M|B|M|ElM|E|M|ElMlB  |M|E 
Fig.  7. — Temperature  Range  in  Cerebro-spinal  Fever,  in  so-called  Intermittent  Form. 


would  indicate.  True  intermittenee,  ia  the  sense  that  the  term  carries 
when  applied  to  ague,  does  not  belong  to  cerebro-spinal  fever.  Ziemsseii 
regards  the  exacerbations  of  fever  as  due  to  the  irregular  progress  of  the 
inflammation  at  the  beginning  and  during  the  course  of  the  attack;  as 
due  to  slight  returns  of  the  inflammation  when  they  occur  during  con- 


CEREBRO-SPINAL    FEVER.  83 

valescence;  and  finally,  as  in  the  retrogressive  stage,  presenting  the  char- 
acter of  the  absorptive  fever,  often  met  with  during  the  retrograde 
metamorphosis  of  purulent  exudations  in  other  serous  membranes  (pleura, 
peritoneum). 

The  pulse  is  as  variable  as  the  temperature.  Diminished  heart-power, 
and  a  tone  so  impaired  that  slight  causes  give  rise  to  extreme  depression 
as  manifested  in  a  rapid,  feeble,  and  compressible  pulse,  characterizes  the 
circulation  in  this  fever. 

The  frequency  of  the  pulse  by  no  means  constantly  corresponds  to  the 
intensity  of  the  febrile  action  and  the  gravity  of  the  other  symptoms. 
It  is  in  many  cases  scarcely  increased  in  frequency  beyond  the  normal,  in 
others  moderately  quickened,  and  again  it  may  be  very  frequent  indeed. 
In  children  it  is  constantly  accelerated.  It  is  rarely  retarded,  in  this 
respect  differing  from  the  pulse  in  tuberculous  basilar  meningitis.  A  slow 
pulse  is  in  some  instances  present  in  the  beginning  of  the  disease,  ere  the 
temperature  has  risen;  but,  as  a  rule,  it  quickly,  with  the  onset  of  marked 
fever-symptoms,  rises  in  frequency.  In  fatal  cases  it  is  often  so  rapid  that 
it  cannot  be  counted.  Perhaps  the  most  constant  character  of  the  pulse 
is  its  variations  in  rapidity.  Within  a  few  hours  it  often  varies  from 
forty  to  fifty  beats  per  minute,  and  a  difference  of  twenty  or  thirty  beats 
may  be  counted  within  the  lapse  of  a  few  minutes.  A  very  rapid  pulse, 
which  continues  so,  is  to  be  regarded  as  unfavorable. 

In  quality,  the  pulse  may  be  normal,  or  its  fulness  and  tension  may  be 
augmented.  When  depression  comes  on,  it  becomes  small,  weak,  and 
often  intermittent.  The  feebleness  and  rapidity  of  the  pulse  in  cases 
tending  to  a  fatal  issue,  and  particularly  in  those  patients  who  rapidly 
approach  death,  is  notable.  To  quote  Githens:  "The  pulse  varied  from 
normal  to  150  beats  per  minute  in  uncomplicated  cases,  and  as  high  as 
160  in  two  puerperal  women;  it  was  in  all  very  weak,  with  dicrotic  ten- 
dency; sometimes  entirely  imperceptible  in  the  radial  artery,  and  always 
interrupted  by  a  very  slight  pressure."  Da  Costa'  has  observed  well- 
marked  blood-murmurs  in  the  heart,  even  early  in  the  course  of  the  dis- 
ease. 

The  7iutrition  of  the  patient  generally  suffers  seriously.  The  wasting 
is  very  rapid  and  extreme  in  severe  cases.  When  death  takes  place  after 
a  long  illness,  the  corpse  presents  a  high  degree  of  emaciation.  This  is 
due  not  alone  to  the  fever  and  grave  inflammatory  lesions  of  the  nervous 
system,  but  the  loss  of  appetite,  obstinate  vomiting,  restlessness  and  pain, 
also  contribute  a  large  share  in  bringing  it  about. 

An  early,  sudden  and  great  loss  of  strength  is  a  frequent  and  promi- 
nent feature  of  this  malady.  Syncope  sometimes  occurs  at  the  beginning 
of  the  sickness.     The  patient  is  not  only  the  victim   of  an  extreme  de- 


'  J.  M.  Da  Costa  :  Medical  Diagnosis.     Philadelphia,  1864. 


84  THE    CONTINUED    FEVERS. 

bility  during  his  illness,  but  he  comes  out  of  it  thoroughly  exhausted,  and 
is  a  long  time  in  regaining  his  strength.  Tiie  prostration  which  is  so 
prominent  a  symptom  of  cerebro-spinal  fever  cannot  be  said  to  be  char- 
acteristic of  this  disease  as  distinguished  from  some  of  the  otlier  continued 
fevers,  but  is  notable  for  the  frequency  with  which  it  occurs,  the  high  de- 
gree which  it  attains,  and  the  early  period  in  the  course  of  the  attack  at 
which  it  appears  in  the  affection  under  consideration.  It  is  to  this  char- 
acter of  the  disease  that  it  owes  the  old  misleading  names  of  "  Sinking 
Typhus,"  "  Typhus  Sj^ncopalis,"  etc. 

SYMPTOMS  REFEEABIiE  TO    THE  ORGANS  OF  RESPIRATION. 

In  mild,  uncomplicated  cases,  the  respiration  is  for  the  most  part  quiet 
and  easy,  though  slightly  accelerated.  Its  rhythm  is  undisturbed.  If 
cough  be  present,  it  is  usually  slight  and  accidental.  In  the  grave  cases 
the  resjiiration  is  more  or  less  disturbed.  It  is  sighing,  labored,  or  in- 
terrupted. As  the  case  draws  to  a  fatal  termination,  the  breathing  be- 
comes more  and  more  embarrassed;  it  grows  very  rapid,  arhythmic,  and 
often  presents  that  alternation  of  respiration  with  respiratory  pauses, 
known  as  the  Cheyne-Stokes  respiration. 

It  is  probable  that  pressure  upon,  or  oedema  of,  the  medulla  oblongata, 
gives  rise  to  the  interrupted  respirations.  There  can  be  no  doubt,  how- 
ever, that  the  tonic  contraction  of  the  spinal  muscles,  and  other  groups 
more  directly  concerned  in  the  perfox'mance  of  the  acts  of  respiration,  has 
much  to  do  with  the  embarrassment  of  breathing,  which  is  still  more 
common. 

The  organs  of  digestion  are  deranged.  In  addition  to  the  vomiting 
which  has  already  been  described,  there  is  nausea  and  more  or  less  com- 
plete loss  of  appetite. 

The  tongue  is  moist  and  coated  with  a  light  or  thick,  white  fur.  In 
cases  attended  with  great  prostration,  and  in  collapse,  the  tongue  is  dry 
and  brown.  If  the  patient  rally  from  the  prostration,  the  tongue  quickly 
becomes  moist  again  with  the  reappearance  of  the  whitish  fur.  It  is  some- 
times clear  at  the  tip  and  edges.  A  moderate  degree  of  retraction  of  the 
belly  is  sometimes  present.  Constipation  is  the  rule.  Diai'rhoea  sometimes 
occurs.  The  latter  is  more  frequent  in  children,  and  in  some  cases  pre- 
cedes the  attack.  If  constipation  be  present,  it  readily  yields  to  the  action 
of  purgatives. 

TJdrst  is  almost  constantly  a  tormenting  symptom.  It  is  unappeas- 
able, and  frequently  persists  till  convalescence. 

Jaundice  occurs  in  a  few  cases.  No  other  symptom  of  disturbance  of 
the  liver  is  noted. 

TJxe  sj)lcen  is  very  rarely  sufficiently  enlarged  to  occasion  an  increase 
of  its  area  of  dulness  discoverable  durinnf  life. 


CEREBRO-.SPINAL    FEVEK.  85 

The  urine  is  sometimes  normal  in  quantity,  oftener  increased.  It 
may  be  much  increased,  even  during  active  fever  with  high  temperature. 
Urates,  as  in  all  fevers,  are  often  thrown  down  as  the  urine  cools.  The 
reaction  is  usually  acid.  A  moderate  amount  of  albumen  is  occasion- 
ally to  be  detected,  and  more  rarely  cylindrical  casts  and  blood-corpus- 
cles. Phosphates  may  be  present.  In  delirium  and  in  coma,  retention 
of  urine  may  be  overlooked,  and  if  catheterization  be  delayed,  cystitis 
may  result. 

Polyuria  is  very  common  in  children,  and  has  been  observed  in  rare 
cases  as  a  symptom  persisting  for  years  after  convalescence.  Transient 
albuminuria  has  also  occurred. 

Inflammation  of  the  joints,  resembling  rheumatism,  is  occasionally  met 
with.  It  is  commonly  slight,  but  in  rare  instances  may  run  on  to  a  sup- 
purative arthritis.     The  wrist-joints  are  most  frequently  affected. 

Swelling  of  the  parotid  glands  \s3in  infrequent  accident  of  the  disease. 
It  may  be  slight,  or  it  may  run  on  to  suppuration.  Tourdes  saw  suppura- 
tive parotiditis  in  two  fatal  cases.  Githens  met  with  it  in  two  out  of 
ninety-eight  cases,  both  of  which  recovered,  and  Stillc  saw  two  or  three 
cases. 

DISTDBBANCES  OP  TECE  OBGANS  OF  THE  SPECIAIj  SENSES. 

The  eye  and  ear  are  frequently  involved,  and  are  often  the  seat  of 
serious  lesions.  It  is  not  known  to  what  extent  the  taste  and  smell  may 
be  affected.  In  mild  cases  the  perception  of  odors  is  normal;  the  taste  is 
perverted,  as  it  is  apt  to  be  in  the  catarrhal  state  of  the  mouth  and  stomach 
which  belongs  to  fever.  In  grave  cases  the  condition  of  the  patient  pre- 
cludes the  investigation  of  this  point.  .1.  Lewis  Smith  ascertained  that 
in  one  nostril  the  sense  of  smell  was  lost  altogether,  in  a  case  under  his 
observation. 

To  return  to  the  consideration  of  the  eye  and  ear. 

TJie  pupil  is  often  normal  during  the  whole  course  of  the  disease.  In 
other  instances  it  dilates  toward  the  end  ;  again  it  is  frequently  contracted 
in  the  beginning,  and  dilates  after  some  days'  sickness;  not  infrequently 
the  pupils  differ  in  size,  one  being  contracted,  the  other  dilated,  and  the 
two  responding  differently  to  the  same  light.  Feeble  response  to  light 
is  a  common  symptom. 

Intolerance  to  bright  light  is  an  almost  constant  symptom. 

Nystagmus  may  occur  in  consequence  of  clonic  spasm  of  the  muscles 
of  the  eyeball,  and  spasm  of  particular  muscles  or  groups  of  muscles  may 
give  rise  to  transient  strabismus,  which  may  appear  and  disappear  several 
times  before  convalescence  sets  in.  Paralysis  of  certain  of  the  ocular 
muscles  also  causes  squint,  which  may  last  several  weeks,  or  even  be  per- 
manent.    Paralysis   of  the  various   cranial  nerves  depends  mostly  upon 


86  THE    CONTINUED    FEVERS. 

the  lesions  consequent  upon  the  extension  of  the  meningeal  inflammation 
to  their  trunks,  and  arises  either  from  the  pressure  exerted  by  the  sur- 
rounding exudation,  or  from  contraction  of  the  hyperplastic  connective 
tissue  of  the  nerve-sheath. 

The  further  lesions  of  the  eye  consist  of  inflammatory  affections  of 
the  organ  of  sight  itself,  and  are:  (a)  inflammatory  hyperiemia  of  the  con- 
junctiva. This  is  of  frequent  occurrence.  There  is  a  uniform  diffused 
redness  of  the  conjunctiva,  not  so  dusky  as  in  typhus.  It  is  an  early 
symptom.  At  times  it  amounts  to  an  intense  conjunctivitis,  with  oedema 
of  the  eyelids  and  a  free  muco-purulent  secretion.  When  it  is  severe  the 
cornea  becomes  opaque  and  the  seat  of  ulceration.  Ziemssen  has  pointed 
out  the  fact  that  this  form  of  destructive  keratitis  is  frequently  due  to 
the  exposure  of  the  cornea  to  the  action  of  the  air,  as  a  result  of  partial 
palsy  of  the  orbicularis  palpebrarum  muscle,  and  consequent  imperfect 
closure  of  the  ej'elids:  (b)  severe,  suppurative  irido-choroiditis,  or  pan- 
ophthalmitis. The  media  grow  cloudy,  the  iris  discolored,  the  pupils  be- 
come irregular  and  are  blocked  with  inflammatory  exudation.  The  storm 
subsides,  leaving  distorted  pupils,  the  lens  cataractous,  the  retina  de- 
tached, and  ultimate  atrophy  of  the  globe  ensues  ;  or,  in  rarer  cases,  the 
eye  is  destroyed  by  perforating  ulceration  of  the  cornea  and  the  forma- 
tion of  anterior  staphyloma  :  (e)  optic  neuritis  terminating  in  atrophy 
of  the  nerve. 

Disturbances  of  hearing  are  noticed  within  the  first  few  days.  The 
patient  is  annoyed  by  loud  sounds  ;  humming  and  ringing  in  the  ears  are 
speedily  followed  by  more  or  less  complete  deafness.  These  manifesta- 
tions are  usually  bilateral.  They  are  due  to  two  processes:  (a)  inflamma- 
tion of  the  middle  ear.  If  it  be  catarrhal  in  character  and  mild,  as  is 
most  commonly  the  case,  it  subsides  without  loss  of  hearing;  if  it  be  puru- 
lent and  severe,  perforation  of  the  membrana  tj'mpani  occurs,  and  an 
otorrhoea  of  variable  duration  ensues  :  {b)  suppurative  inflammation  of 
the  labyrinth,  with  destruction  of  the  membranous  labyrinth.  The  patient 
loses  his  hearing  without  otorrhoea,  otalgia,  or  other  local  symptom.  The 
loss  of  hearing  does  not  always  come  on  at  the  same  period  of  the  disease; 
tlie  majority  of  cases  are  observed  to  be  deaf  as  soon  as  the  stupor  goes 
off  and  full  consciousness  returns,  while  in  rarer  instances  those  who  be- 
come deaf  are  able  to  hear  more  or  less  distinctly  at  this  time,  but  lose 
this  function  in  the  course  of  the  convalescence.  This  form  of  deafness 
is  complete  and  permanent.  It  affects  both  ears,  and  has  been  observed 
in  some  instances  to  be  associated  with  a  staggering  gait.'  It  is  probable 
that  the  inflammation  makes  its  way  within  the  sheath  of  the  auditory 
nerve  (A.  Heller). 


'  See  Proceediugs  of  Philadelphia  Pathological  Society,  Philadelphia  Medical  Times, 
January  31,  1874. 


CEREBKO-y PINAL    FEVER.  87 

Serious  lesions  of  the  eye  and  ear,  resulting  in  the  permanent  and 
complete  loss  of  sight  and  hearing,  occur  in  some  cases  that  run  a  mild 
course  as  regards  the  general  phenomena  of  the  affection.  Dr.  Schaffner' 
records  a  case  in  which  a  boy  aged  six,  after  a  sickness  of  two  weeks  with 
symptoms  of  mild  character,  complained  of  blindness.  On  examination 
the  loss  of  sight  was  found  to  be  due  to  optic  neuritis. 

Complications  and  Sequels. 

Some  of  the  complications — those  involving  the  eye  and  ear,  the  joints 
and  the  parotid  glands — have  already  been  considered  in  the  analysis  of 
the  symptoms. 

Catarrhal  and  croupous  pneumonia,  bronchial  catarrh,  pleurisy,  endo- 
carditis, pericarditis,  also  occur  as  complications  in  some  cases  of  almost 
every  epidemic.  Atelectasis  and  broncho-pneumonia  are  more  common 
in  those  patients  who  for  a  long  time  have  suffered  from  orthotonus 
(Ziemssen).  The  combination  of  croupous  pneumonia  with  cerebro-spinal 
fever  has  been  observed  to  be  of  common  occurrence  in  some  of  the  re- 
cent German  epidemics.  This  serious  complication  has  been  encoun- 
tered with  greater  frequency  at  the  close  than  at  the  beginning  of  the 
epidemic,  "as  if  the  infectious  poison  had  then  lost  its  violence,  and  was 
able  to  resume  its  activity  only  when  aided  by  the  force  of  other  dis- 
eases." 

Intestinal  catarrh  also  occurs  as  a  complication.  Malarial  and  enteric 
fcvei",  and  measles,  scarlet  fever  and  cholera,  have  been  met  with  as  inter- 
current affections. 

Convalescence  is  irregular  and  uncertain.  After  severe  cases  it  is  apt 
to  be  tardy.     Relapses  are  not  uncommon,  and  are  often  fatal. 

The  sequels  are:  {a)  prolonged  debility  and  emaciation,  dyspepsia, 
boils,  carbuncles  due  to  the  blood-changes  that  take  place  in  this  as  in 
other  infectious  diseases;  and  {b)  those  due  to  the  lesions  resulting  from 
the  inflammation  of  the  brain  and  cord,  and  their  membranes,  and  its  ex- 
tension to  the  organs  of  the  special  senses,  namely:  pareses  and  paralyses, 
impairment  of  intelligence  in  consequence  of  chronic  meningitis  and 
chronic  hydrocephalus,  and  more  or  less  complete  deafness  and  loss  of 
vision. 

General  motor  loeakness  a,x\({  paralyses  of  single  extremities  or  partic- 
nlar  nerves  are  not  very  infrequent.  They  depend  upon  lesions  of  the 
brain  or  spinal  cord,  or  on  the  results  of  injury  to  the  parts  in  consequence 
of  the  pressure  exerted  by  the  contraction  of  the  organized  inflammatory 
exudation. 

Feebleness  of  the  intelligence  and  weakness  of  nieniory,  with  defects  of 


'  Philadelphia  Medical  Times,  May  16,  1874. 


88  TJIE    CONTINUED    FEVEKS. 

speech,  are  often  sequels.  In  most  cases,  they  gradually  disappear  in  the 
course  of  some  weeks  or  months,  and  when  permanent  are  the  result  of 
chronic  inflammatory  processes  affecting  the  brain. 

On©  of  the  most  important  of  the  cerebral  affections  left  by  this  fever 
is  chronic  hydrocephalus. 

The  symptoms  are  paroxysmal;  they  consist  of  severe  headache,  in- 
tolerance of  light  and  sound,  vertigo,  pains  in  the  neck  and  limbs,  vom- 
iting, involuntary  discharges,  convulsions,  loss  of  consciousness.  The 
attacks  occur  either  at  long  and  irregular  intervals  or  in  rapid  succession. 
The  mental  and  bodily  condition  of  the  patient  during  the  intervals  is 
sometimes  such  as  to  lead  to  delusive  hopes  of  his  recovery.  If  partial 
recovery  take  place  the  mind  remains  weak,  and  the  limbs  paralyzed  and 
deformed.  In  the  rarest  of  instances  has  an  approach  to  complete  recov- 
ery been  recorded. 

In  a  majority  of  instances  the  condition  in  the  intermissions  is  such  as 
to  preclude  all  expectation  of  recovery,  the  mind  being  irritable  and  un- 
steady, the  limbs  slightly  palsied,  muscular  movements  inco-ordinate,  and 
the  development  of  the  body  in  the  young  retarded.  The  head  is  large, 
the  skull  thin,  and  the  eyes  prominent.  Headache  is  a  common  symj)- 
tom. 

Ziemssen  gives  the  following  account  of  the  successive  anatomical 
changes  which  attend  the  development  of  this  process,  as  the  result  of  his 
autopsies  during  the  epidemic  and  in  following  years: 

"  During  the  second  week  the  meningeal  exudation,  which  has  hitherto 
been  little  changed,  or  perhaps  somewhat  thickened,  undergoes  fatty  de- 
generation of  the  cells  and  fibrin,  and  is  thus  slowly  or  rapidly  absorbed, 
or  ultimately  shrinks  into  caseous  matter,  if  absorption  does  not  occur; 
the  connective  tissue  of  the  ai-achnoid  and  pia  mater  proliferates,  the  hyper- 
iemia  of  the  substance  of  the  brain  disappears,  and  the  purulent  effusion 
in  the  ventricles  increases.  From  the  twenty-seventh  to  the  thirtieth  week 
the  arachnoid  and  pia  mater  exhibit  a  pulpy  hyperplasia  or  already  a  cica- 
tricial thickening;  the  caseous  remains  of  the  meningeal  exudation  are  still 
more  shrunken;  the  ventricular  effusion  has  become  more  moderate  in 
amount,  but  quite  clear,  owing  to  the  inspissation  of  the  cellular  elements 
into  small,  caseous  flakes  on  the  dependent  parts  of  the  ventricles.  The 
earlier  hyperemia  of  the  brain  is  completely  gone;  the  brain  is  an;i?mic, 
even  oedematous;  the  ependyma  of  the  ventricles  thickened  and  distinctly 
granulated,  and  the  choroid  plexus  bloodless.  Unless  the  hydrocephalic 
effusion  be  moderate,  the  brain-substance  is  atrophied  sometimes  to  a  very 
considerable  degree.  In  a  boy  two  years  of  age  we  found  the  medullary 
and  cortical  layers  of  the  cerebrum  together  only  seven  and  a  half  lines  in 
thickness,  while  the  central  ganglia  were  much  flattened." 

The  same  author  states  that  the  interval  of  apparently  progressive 
convalescence  which  usuallv  occuis  between  the  acute  stasje  of  the  mcnin- 


CEREBRO-SPINAL    FEVER.  89 

gitis  and  the  appearance  of  the  symptoms  of  hydrocephalus,  renders 
probable  the  supposition  that  the  increase  of  the  ventricular  effusion  may 
be  due  to  the  shrinking  and  thickening  of  the  pia  mater. 

The  various  lesions  of  the  eye  and  ear  that  give  rise  to  defects  of  or 
loss  of  sight  and  hearing,  as  sequels,  have  already  been  pointed  out. 
These  lesions  are  either  the  result  of  the  extension  of  the  inflammatory 
process  from  the  pia  mater  along  the  sheath  of  the  optic  and  auditory 
nerves  to  the  respective  organs,  or  of  a  simultaneous  localization  of  the 
inflammation  in  the  pia  mater  and  the  eye  and  its  tunics,  and  in  the  pia 
mater  and  the  labyrinth  and  tympanum,  as  effects  of  a  single  disease- 
producing  cause. 

Complete  deafness  in  young  children  who  have  not  yet  learned  to 
talk,  and  even  in  those  who  have  more  or  less  perfectly  acquired  the  power, 
results  in  deaf-mutism.  In  those  who  have  learned  to  talk,  speech  is, 
after  several  months,  understood  with  difficulty,  and  gradually,  in  the 
course  of  a  year  or  more,  becomes  quite  unintelligible.  It  is  necessary 
for  such  children  to  be  sent  to  institutions  for  the  education  of  deaf- 
mutes. 

Some  observers  have  noticed  that  deaf-mutism  is  an  uncommon  result 
of  this  fever,  even  when  complete  deafness  occurs,  and  Hirsch  has  called 
attention  to  the  fact  that  impairment  of  speech,  and  even  aphasia,  may 
arise  coincidently  with  the  loss  of  hearing  as  a  co-effect  of  the  meningeal 
inflammation.  When  the  loss  of  speech  is  a  result  of  the  deafness,  it  is 
preserved  for  a  time  after  the  meningitis  subsides,  and  gradually  grows 
more  and  more  imperfect,  till  it  is,  as  articulate  language,  lost  altogether. 


Pathology,  Morbid  Anatomy. 

The  essential  pathological  processes  in  cerebro-spinal  fever  are  two- 
fold: (a)  the  constitutional  disturbances  due  to  the  direct  action  of  the 
infecting  poison  upon  the  blood,  giving  rise  to  the  group  of  symptoms 
constituting  fever;  and  {b)  the  local  inflammation.  As  is  seen  by  the 
foregoing  study  of  the  clinical  phenomena  of  the  disease,  one  or  the 
other  of  those  processes  may  predominate,  and  the  course  and  symptoms 
of  the  attack  vary  accordingly.  If  the  phenomena  of  infection  are  most 
conspicuous,  and  the  symptoms  of  the  local  inflammation  are  but  slight- 
ly developed,  the  affection  presents  striking  resemblances  to  some  of 
the  other  infectious  diseases,  while  on  the  other  hand  the  latter  symp- 
toms may  be  so  prominent  as  to  overshadow  the  infectious  nature  of  the 
affection,  and  present  the  appearance  of  a  simple  inflammation  with 
attendant  symptomatic  fever.  The  latter  form  is  met  with  during  the 
epidemic  prevalence  of  the  disease,  but  is  most  common  in  the  sporadic 
cases. 


90  THE    CONTINUED    FEVEUS. 

Between  these  two  extremes  every  variety  of  combination  of  the  two 
processes  is  to  be  encountered,  but  in  all  a  careful  study  of  the  course  and 
symptoms  of  the  attack  will  reveal  the  manifestations  of  both. 

In  like  manner  tiie  morbid  anatomy  reveals  the  lesions  due  to  the  in- 
fective character  of  the  disease,  and  those  resulting  from  the  local  inflam- 
mation which  is  its  constant  attendant. 

These  lesions  are  constant.  They  vary  only  in  the  degree  of  their 
development. 

The  emaciation,  in  cases  of  long  duration,  is  extreme. 

Cadaveric  rigidity  is  marked  and  long  continued. 

Exteiisivc  discolor ations  of  the  dependent  parts  rapidly  show  them- 
selves. Large  patches  of  a  livid  hue  may  even  appear  elsewhere  upon 
the  body. 

Stille  has  published  the  account  of  a  case  in  which  the  whole  body 
became  rapidly  almost  black,  during  the  two  hours  before  death,  but  the 
countenance  afterward  nearly  regained  its  natural  hue.  As  a  rule  the 
purpuric  spots  on  the  anterior  surface,  the  redness  of  the  eyes  and  the 
like,  fade  as  the  staining  of  the  posterior  parts  of  the  cadaver  deepens. 

The  skin  shows  the  vesicles  and  crusts  of  herpes,  the  mottlings  and 
staining  of  petechiee.  Patches  of  superficial  gangrene,  and  bed-sores  are 
sometimes  seen. 

T7ie  muscles  are  dry,  soft,  brownish  red,  sometimes  pale,  and  atrophied. 
They  are  found  to  have  undergone  granular  degeneration.  These  changes 
especially  affect  the  muscles  extending  along  the  spinal  column. 

The  heart  is  often  flabby,  and  contains  dark,  thin  fluid  blood,  with 
loose  soft  coagula,  or  less  frequently  it  contains  fir/n  fibrinous  clots.  The 
cardiac  muscle  shows  the  same  histological  changes  as  the  voluntary  mus- 
cles.    In  the  fulminant  variety  it  is  unchanged. 

Klebs  '  found  the  condition  of  the  blood  very  variable.  In  rapidly 
fatal  cases  it  was  very  fluid  and  the  clots  were  soft  and  scanty.  Dr. 
Levick '  states  that  the  blood  is  in  all  cases  fluid.  Upon  microscopical 
examination,  the  red  corpuscles  are  shrivelled,  crenated,  not  formed  into 
rouleaux,  and  "  numerous  white  corpuscles  are  found  in  the  field." 

Multiple  abscesses  have  been  found  both  in  the  subcutaneous  connec- 
tive tissue,  and  in  that  of  the  intermuscular  planes.  When  the  joints 
have  been  swollen  and  tender  during  life,  they  have  been  found  the  seat 
of  sero-purulent  effusions. 

The  lungs  show  frequent  changes.  Hyperemia,  hypostatic  conges- 
tions, oedema,  bronchitis  with  a  tenaceous  secretion,  are  often  met  with. 
The  infiltrations  of  catarrhal  and,  less  frequently,  of  croupous  pneumonia, 
are  also  encountered. 


'  Zur  Pathologie  der  epidemischen  Meningitis.     Virchow's  Archiv,  xxxiv. 
-  See  Report  of  the  Committee  on  "  Spotted-Fever,  so  called,"  by  James  J.  Levick, 
M.D.     Transactions  American  Association,  vol.  xvii.,  18(j6. 


CEREBUO-SPINAL    FEVER.  91 

The  pleuroe,  ami pericardiuin  are  sometimes  inflamed,  ecchymosed,  and 
contain  purulent  exudation. 

Recent  endocarditis  is  rare. 

The  liver  is  congested,  but  rarely  enlarged.  Its  cells  show  a  granular,, 
albuminoid,  or  fatty  cloudiness  (Klebs). 

The  spleen  is  very  variable  in  size.  It  is  usually  small,  but  sometimes 
moderately,  never  greatly  enlarged.     It  is  usually  softened. 

The  intestinal  mucous  memhrane  is  usually  normal.  It  is  sometimes 
injected  and  thickened.  The  solitary  and  agminate  glands  are  enlarged 
and  sometimes  ulcerated. 

The  lymphatic  glands  nearly  always  present  a  reddened  appearance. 

The  kidneys  are  generally  congested.  The  tubules  are  sometimes 
blocked  with  fat-granules  and  fibrinous  casts. 

The  lesions  thus  far  described  are  for  the  most  part  those  met  with 
after  death,  from  infectious  diseases  in  general,  and  are  not  distinctive. 
Those  which  we  now  come  to  discuss  are  as  characteristic  as  the  intestinal 
lesions  of  enteric  fever.  They  are  the  results  of  the  inflammator}^  pro- 
cesses which  have  their  seat  in  the  cerebro-spinal  axis  and  its  enveloping 
membranes. 

The  calvarium  in  many  instances  shows  no  change;  it  is  most  fre- 
quently congested,  especially  in  the  line  of  the  sutures. 

The  dura  mater  of  the  brain  is  often  tense,  smooth  on  the  outer  sur- 
face, at  points  firmly  attached  to  the  inner  table  of  the  skull,  and  show- 
ing scattered  punctiform  hemorrhages  or  small  effusions  of  blood;  the 
inner  surface  hypersemic,  and  more  or  less  closely  adherent  to  the  arach- 
noid. 

The  sinuses  are  distended  with  thin  fluid  blood,  and  contain  soft  post- 
mortem clots  or  firm  thrombi. 

The  arachnoid  is  often  found  quite  normal,  especially  in  cases  that 
have  run  a  rapid  course;  it  is  sometimes  hyperaemic  or  stained  with  blood, 
or  again  it  may  be  dry,  lustreless,  and  opaque.  The  space  between  the 
dura  and  the  arachnoid  has  been  observed  to  contain  a  considerable 
quantity  of  serous  effusion,  or  more  rarely  of  pus. 

After  a  protracted  illness,  when  the  exudation  has  begun  to  become 
organized,  the  arachnoid  is  rough  and  thickened. 

The  jt>ia  mater  is  hyperjemic,  with  intense,  diffuse  capillary  injec- 
tion and  points  of  capillary  hemorrhage.  It  is  adherent  to  the  surface 
of  the  brain,  from  which  it  can  be  separated  with  difficulty,  and  often 
only  by  tearing  the  brain -substance.  In  those  cases  which  end  fatally  in 
the  course  of  a  few  hours,  this  hyperajmia  is,  as  a  rule,  the  only  change 
in  the  meninges  discoverable  by  the  unaided  eye.  Free  exudation  is  ab- 
sent. But  upon  microscopical  investigation  the  pia  mater  is  found  to  be 
densely  infiltrated  with  cells,  especially  along  the  line  of  the  vessels.  If 
the  case  have  been  a  more  protracted  one,  this  membrane  becomes  cedema- 


•92  THE    CONTINUED    FEVERS. 

tous  from  the  transudation  of  serum  into  its  meshes,  and  in  one  or  two 
days,  a  cloudy  serum,  or  a  thin,  yellowish  exudation  accumulates  in  the 
sub-arachnoid  space.  By  the  second  or  third  day  the  exudation  is  found 
to  be  distinctly  purulent,  of  a  butter-like,  gelatinous,  or  firmer  consistence, 
and  from  one  to  four  lines  in  thickness.  It  is  of  a  yellowish  or  greenish 
color,  or  may  be  deeply  tinged  with  blood.  It  is  at  times  distributed  in 
a  broad  layer  over  considerable  spaces,  both  on  the  convexity  and  at  the 
base,  most  abundant  in  the  sulci,  along  the  course  of  the  vessels,  over  and 
around  the  optic  chiasm,  over  the  pons  Varolii,  the  cerebellum,  medulla 
oblongata,  and  in  the  great  fissures  of  the  brain.  In  rare  cases  the  exuda- 
tion uniformly  covers  the  whole  surface  of  the  brain.  It  sometimes  ex- 
tends in  strips  along  the  vessels  and  in  the  integral  spaces,  at  others  it 
is  scattered  in  detached,  island-like  plaques.  The  extent  of  the  exudation 
and  its  amount  vary  greatly  in  dilferent  cases.  No  part  of  the  pia  of  the 
brain  or  cord  may  be  free,  or  it  may  be  limited  to  patches  or  strips  on 
the  convexity,  at  the  base,  or  on  the  cord.  It  occupies  the  subarachnoid 
space;  the  arachnoid  space  is  free.  The  thickening  of  the  visceral  arach- 
noid is  due  to  purulent  infiltration.  The  seat  of  the  primary  inflamma- 
tion is  the  pia  mater.  The  exudation  consists  of  fibrin,  mucine,  pus-cells, 
xind  free  granules. 

The  membranes  of  the  spinal  cord  present  similar  anatomical  changes. 
The  dura  is  often  separated  from  the  vertebra;  by  collections  of  extrava- 
sated  blood,  its  inner  surface  smooth,  or  in  many  cases  injected  or  slightly 
adherent  to  the  arachnoid;  or  finally,  collections  of  serum  or  pus  occupy 
regions  of  the  space  between  these  two  membranes.  The  arachnoid  is  often 
normal,  in  other  cases  cloudy  and  infiltrated  with  pus.  The  pia  is,  as  in 
the  brain,  but,  as  a  rule,  less  deeply  and  less  extensively  hyper^emic.  It 
is  also  roughened,  thickened,  and  intimately  adherent  to  the  substance  of 
the  cord.  The  exudation  here  also  appears  early  as  a  cloudy  serum,  but 
a  little  later  in  bands  or  strings  of  fibrino-pus,  which  often  assume  an  ir- 
regular, net-like  appearance,  and  later  still  as  thick  layers  of  pus,  resem- 
bling in  ail  its  character  the  exudation  described  above.  Its  seat  is  almost 
exclusively  upon  the  posterior  surface  of  the  cord,  very  rarely,  and  never 
wholly,  in  the  cervical  portion,  but  commonly  extending  from  the  cervical 
to  the  dorsal  enlargement  of  the  cord  downward  to  the  Cauda  equina,  and 
it  is  most  abundant  in  the  lumbar  region.  The  roots  of  the  spinal  nerves 
are  frequently  imbedded  in  it.  The  anterior  surface  is  much  less  rarely 
the  seat  of  the  exudation,  and  when  this  is  the  case,  the  wliole  cord  is 
surrounded. 

According  to  Hirsch,  the  accumulation  of  the  exudation  upon  the  lower 
portion  and  the  posterior  surface  of  the  cord,  is  chiefly  due  to  the  fact  that 
it  flows  there  by  gravitation  whilst  fluid,  and  Ziemssen  observes  that  in  the 
rare  cases  where  the  whole  cord  is  imbedded,  the  variation  from  the  rule 
depends  mainly  upon  the  viscidity  of  tlie  exudation  from  the  beginning. 


CEREBRO-SPIWAL    FEVER.  93 

The  hrain-subatance  is  frequently  congested,  with  numerous  "puncta 
vasculosa  "  upon  the  incised  surface,  and  the  secondary  development  of 
local  areas  of  softening-,  which  are  most  abundant  in  the  neighborhood  of 
the  purulent  exudation  and  about  the  ventricles.  The  nerve-elements 
are  more  or  less  disassociated  as  a  result  of  the  imbibition  of  fluids.  Oc- 
casionally the  entire  brain  is  somewhat  softened.  In  rare  instances  it  is 
oedematous,  even  after  an  illness  of  only  a  few  days.'  This  condition  is 
more  common  in  cases  that  have  been  very  acute  or  very  long-continued. 
The  latter,  class  of  cases  present  a  brain  with  a  smooth,  level  surface,  and 
a  watery  appearance  on  section.  More  rarely  the  consistence  of  the  brain 
is  firmer  than  normal.  In  most  cases,  and  in  particular  in  those  in  which 
the  illness  has  been  protracted,  the  ventricles  contain  more  or  less  turbid 
serum,  and  in  some  cases  they  are  distended  with  pus.  The  choroid 
plexus  and  the  ependyma  are  deeply  congested,  or  even  ecchymosed,  and 
covered  with  pus  and  lymph.  The  same  anatomical  changes  are  found 
in  the  third  and  fourth  ventricles.  In  cases  terminating  after  a  long  ill- 
ness, the  effusion  may  reach  an  enormous  amount,  and  give  rise  to  atrophy 
of  the  brain-substance  with  flattening  of  the  convolutions,  and  oedema  of 
the  brain  and  spinal  cord. 

The  retrogressive  changes  consist  of  resorption  of  the  sei'ous  effusion, 
shrinking  and  organization  of  the  exudation  between  the  arachnoid  and 
pia  mater,  with  opaque  thickening  of  these  membranes  or  caseous  degen- 
ei-ation  of  the  exudation.  In  rare  instances,  diffuse  purulent  encephalitis 
takes  place  and  purulent  infiltration  of  the  brain-substance  or  deposits  of 
pus  are  found  at  the  necropsy. 

Like  changes  are  met  with  in  the  suhstmice  of  the  spinal  cord,  namely, 
hyperaimia,  serous  infiltration,  and  softening.  They  are  less  marked,  as 
a  rule,  and  less  uniformly  distributed. 

In  a  girl,  aged  fourteen,  who  died  on  the  fourth  day,  the  autopsy  dis- 
closed a  large,  serous  effusion,  purulent  exudation  into  the  ventricles,  in- 
cluding the  fourth,  and  dilatation  of  the  central  canal  of  the  cord,  which 
was  filled  with  pus  (Ziemssen). 

In  cases  of  the  fulminant  variety,  where  death  quickly  follows  the  on- 
set of  the  sickness,  it  is  probable  that  the  subject  is  overwhelmed  by  the 
poison  ere  the  characteristic  anatomical  changes  have  time  to  develop, 
as  occurs  in  rapidly  fatal  cases  of  other  epidemic  and  infectious  diseases, 
as  variola,  scarlatina,  etc. 

The  amount  of  the  exudation  and  the  extent  of  the  secondary  changes 
in  the  substance  of  the  brain  and  cord,  are  not  always  proportionate  tO' 
the  intensity  of  the  symptoms  or  the  duration  of  the  case. 


Hutchison:  American  Journal  Medical  Sciences,  July,  1866. 


:94  THE    CONTINUED    FEVERS. 


Diagnosis. 

The  direct  diagnosis  of  epidemic  cerebro-spinal  fever  usually  pre- 
sents but  little  difficulty  if  the  attack  be  primary  and  occur  during  the 
-epidemic  prevalence  of  the  disease.  Under  certain  circumstances,  as 
when  it  develops  as  an  intercurrent  affection  in  pneumonia,  typhoid  fever, 
or  other  acute  diseases,  or  vv^hen  very  young  infants  are  the  subject  of  the 
attack,  and  when  sporadic  cases  occur  either  beyond  the  limits  of  the 
territory  in  which  the  disease  is  rife,  or  at  the  beginning  of  the  outbreak, 
the  diagnosis  is  attended  with  the  greatest  difficulty,  and  often  cannot  be 
made  until  some  days  have  elapsed. 

The  character  of  an  epidemic  outbreak  of  the  disease  may  be  inferred 
from  the  suddenness  of  its  oncoming  and  the  rapidity  of  its  spread. 

The  diagnosis  of  individual  cases  is  based  upon  the  presence  in  vary- 
ing combinations  of  the  characteristic  symptoms  of  the  affection.  Most 
prominent  among  these  are,  furious  headache,  with  acute  pains  in  the 
neck,  spine,  and  extremities,  faintness,  with  a  sinking  sensation  in  the 
epigastrium,  and  vomiting  which  is  uncontrollable;  and  contraction,  first 
of  the  cervical  muscles,  later  of  those  of  the  spine,  with  general  cutane- 
ous hyperaisthesia.  Add  to  these  morbid  phenomena  the  abruptness  of 
the  attack,  with  or  without  prodromes;  extreme  restlessness;  delirium  al- 
ternating with  periods  of  quasi-consciousness  and  merging  into  stupor  or 
•coma;  the  occasional  convulsive  spasms;  the  eruptions,  especially  herpes; 
the  irregular  temperature,  and  the  extraordinary  variations  of  the  pulse 
in  frequency  and  volume,  and  the  case  presents  a  picture  not  difficult  of 
recognition. 

The  uncertainties  which  beset  the  diagnosis  of  sporadic  cases  of  the 
affection  arise  from  its  less  abrupt  onset,  its  less  acute  course,  the  fre- 
quently indistinct  spinal  symptoms  and  the  great  rarity  of  its  occurrence. 
In  these  cases,  also,  the  pains  in  the  back  and  limbs,  the  orthotonus  and 
the  hyperajsthesia  of  the  skin  and  soft  parts,  are  often  altogether  wanting, 
and  the  stiffness  of  the  neck  is  less  perfectly  developed  than  in  the  epi- 
demic disease. 

Tuherculoiis  basilar  meningitis  is  to  be  distinguished  from  cerebro-spi- 
nal fever  by  the  long  duration  of  the  period  of  prodromes,  which  is  rarely 
absent,  by  the  less  abrupt  and  less  violent  onset,  by  its  slower  course 
marked  with  remissions,  its  slow  pulse,  the  great  irregularity  of  the  res- 
piration, and  the  absence  of  eruptions.  Furthermore,  there  will  usually 
be  elicited  some  history  of  scrofulous  and  phtiiisical  affections,  or  of  a 
hereditary  tendency  to  tuberculous  disease.  But  in  children,  or  during 
the  prevalence  of  an  epidemic  of  cerebro-spinal  fever,  or  in  those  cases  in 
which  the  tuberculous  process  extends  to  the  membranes  of  the  spinal 
cord  (Hirsch),  the  diagnosis  is  far  from  easy. 


CEREBROSPINAL    FEVER. 


^5 


Pernicious  intermittent  fever,  with  its  fulminant  manifestations,  its 
speedy  collapse  and  fatal  coma,  may  be  confounded  with  the  fulminant 
variety.  The  diagnosis  rests  upon  a  consideration  of  the  etiological  fac- 
tors of  the  two  diseases.  The  season  of  the  year,  the  nature  of  the 
country,  which  is  usually  in  the  highest  sense  insalubrious,  and  the  en- 
demic or  epidemic  prevalence  of  ordinary  intermittent  or  remittent  fever, 
tend  to  clear  up  the  obscurity  arising  from  any  accidental  resemblance  of 
the  symptoms.  Moreover,  an  attack  of  intermittent  fever  rarely  declares 
itself  as  pernicious  or  malignant  in  the  first  paroxysm;  it  is  only  after  one, 
two,  or  more  seizures,  differing  not  at  all,  or  but  slightly,  from  the  common 
manifestation  of  the  disease,  that  it  discloses  its  true  character. 

Scarlet  fever  in  some  instances  may  resemble,  in  its  sudden  onset,  high 
febrile  movement,  vomiting,  convulsions  and  stupor,  cerebro-spinal  fever 
as  it  occurs  in  children.  The  presence  of  the  peculiar  redness  of  the 
palatine  half-arches,  which  is  characteristic  of  the  former  disease  in  its 
earliest  stage,  may  aid  in  the  diagnosis.  In  a  few  hours  the  efflorescence 
will  clear  up  any  uncertainty. 

Enteric  fever  in  its  typical  form  presents  marked  points  of  differ- 
ence from  the  fever  under  consideration.  Yet  it  has  in  more  than  one 
local  outbreak  presented  symptoms  that  have  for  a  time  rendered  it 
doubtful  which  of  the  two  diseases  was  present. 

The  following  brief  tabular  arrangement  of  the  prominent  symptoms 
will  serve  to  contrast  the  two  diseases: 


Cerebro-spinal  Fever. 

Abrupt,  overwhelming  onset,  with  or 
without  prodromes. 

Headache,  acute,  agonizing. 

Vomiting,  constant. 

Muscular  contraction  within  the  first  two 
or  three  days. 

Constipation  the  rule. 

Active  delirium,  alternating  with  stupor, 
or  stupor  deepening  into  coma. 

Curve  of  temperature  extremely  irregu- 
lar and  atypical. 

Attack  reaches  its  maximum  within 
four  or  five  days. 

Various  eruptions,  chiefly  herpetic  and 
petechial ;  they  appear  early. 


Enteric  Fever. 

Gradual  approach    with    marked    pro- 
dromes, and  often  obscure  beginning. 
Headache,  dull,  heavy. 
Rare. 
Absent  altogether. 

Diarrhcea  the  rule. 

Mental  hebetude,  muttering  delirium, 
stupor. 

A  typical  thermal  line. 

Develops  slowly  to  its  maximum. 

A  characteristic  lenticular,  rose -colored 
eruption,  which  does  not  appear  until  the 
end  of  the  first  week. 


Much  confusion  has  arisen  from  the  fact  that  not  a  few  among  the 
older  writers,  and  some  of  a  later  date,'  have  confounded  cerebro-spinal 


See  Murchison :  London  Lancet.     April,  1865. 


96 


THE    CONTINUED    FEVEKS. 


fever  with  t>/p/'"-^',  or  regarded  it  as  a  variety  of  t>/2^/ufs.  Tliesc  diseases 
are  not  only,  as  is  at  tliis  day  universally  admitted,  unlike  in  every  respect 
save  their  infectious  nature,  but — as  has  been  pointed  out  by  Stille,  whose 
learned  treatise  has  done  much  to  finally  settle  every  question  of  doubt 
concerning  the  identity  of  these  two  diseases  in  this  country — they  are 
also  in  strong  contrast  in  respect  of  their  causes,  symptoms,  course,  lesions 
and  sequels,  and  all  physicians  who  have  witnessed  epidemics  of  both  af- 
fections agree  in  pronouncing  them  to  be  radically  different. 

I  venture  to  transcribe,  from  the  pages  of  the  last  named  author,  a  table 
of  the  important  phenomena  of  these  two  affections,  believing  that,  by  so 
doing,  their  essential  independence  and  the  striking  points  of  differential 
diagnosis  between  them  will  be  most  clearly  demonstrated: 


Ei'iDEjiic  Meningitis  (Cerebro-spinal 

Fever). 

A  pandemic  disease.  Occurs  in  places 
remote  from  one  another,  and  without  in- 
tercommunication. 

Attacks  all  classes  of  society.  Is  never 
primarily  developed  by  squalor  and  de- 
ficient ventilation. 

Is  not  contagious. 

More  males  than  females  attacked. 

More  young  persons  than  adults. 

Generally  occurs  in  winter. 

Eruptions  are  wanting  in  at  least  half  of 
the  cases ;  they  occur  within  the  first  day 
or  two. 

The  eruptions  are  very  various,  including 
erythema,  roseola,  urticaria,  herpes,  etc. 
Ecchymoses  are  common. 

Headache,  acute,  agonizing,  tensive. 

Delirium  often  absent ;  often  hysterical, 
sometimes  vivacious,  sometimes  maniacal. 
Generally  begins  on  the  first  or  second  day. 

Pulse  very  often  not  above  the  natural 
standard ;  often  preternaturally  frequent 
or  infrequent.  Is  subject  to  sudden  and 
great  variations. 

"  The  temperature  is  lower  than  that 
recorded  in  any  other  typhoid  or  inflam- 
matory disease."  It  is  also  very  fluctu- 
ating. 

The  body  has  no  peculiar  smell. 

The  tongue  is  generally  moist  and  soft ; 
Bordes  of  the  teeth,  etc.,  rare. 


Typhus  Fever. 


Essentially  an  endemic  disease.  Always 
due  to  local  causes.  Spreads  by  inter- 
communication only. 

Attacks  primarily  the  poor,  filthy,  and 
crowded  alone. 

Contagious  to  a  high  degree. 

The  two  sexes  equally  affected. 

More  adults  than  young  persons. 

Ejndemics  are  irrespective  of  season. 

The  eruption  is  rarely  absent,  and  dis- 
appears between  the  fourth  and  the  seventh 
days. 

The  eruption  is  uniformly  roseolous  and 
then  petechial.     Ecchymoses  are  rare. 

Headache,  dull  and  heavy. 
Rarely  absent ;  usually  muttering.  Rare- 
ly begins  before  the  end  of  the  first  week. 

A  slow  pulse  exceedingly  rare.  Its  rate 
is  pretty  constantly  between  90  and  120. 


The  temperature  is  always  more  or  less 
elevated,  and  it  does  not  fall  until  the  close 
of  the  disease.  ' '  The  skin  is  hot,  burning 
and  pungent  to  the  feel." 

The  mouse-like  odor  of  typhus  is  char- 
acteristic. 

The  tongue  is  generally  dry,  hard,  and 
brown  ;  and  the  teeth  and  gums  fuliginous. 


CEREBRO-SPINAL    FEVER. 


97 


Epidemu:  Meningitis  (Cerebro-spinal  , 
Fever). 

Vomiting,  generally  of  bilious  matter,  is 
aa  almost  constant  and  urgent  symptom, 
especially  in  the  first  stage. 

Pains  in  the  spine  and  limbs,  of  a  sharp 
aad  lancinating  character,  are  usual  and 
evidently  neuralgic. 

Tetanic  spasms  in  a  very  large  proportion 
of  cases,  and  within  the  first  two  or  three 
days.  They  are  due  to  an  inflammatory 
exudation  within  the  spinal  canal. 

Cutaneous  hyperjesthesia  is  a  common 
symptom. 

Strabismus  common. 

The  eye,  if  injected,  has  a  light  red  or 
pinkish  color. 

The  pupils  are  often  unequal. 

Deafness  often  complete  and  permanent. 

Duration  very  indefinite,  but  generally 
from  four  to  seven  days. 

Relapses  are  common. 

The  blood  is  often  highly  fibrinous. 

The  lesions,  unless  in  the  most  rapid 
cases,  consist  of  a  fibrinous  or  purulent 
exudation  in  the  meshes  of  the  cerebro- 
spinal pia  mater. 

Mortality  from  twenty  to  seventy-five 
per  cent. 


Typhus  Fever. 


Vomiting  is  rare  and  not  urgent. 


Pains  are  dull,  heavy,  and  apparently 
muscular. 

Tetanic  spasms  are  unknown  in  typhus. 
Convulsions  sometimes  occur,  due  to  "  py- 
semia." 

The  sensibility  of  the  skin  is  generally 
blunted. 

Rare. 

The  blood  in  the  conjunctival  vessels  has 
a  dark  hue. 

Always  equal. 

Hardly  ever  permanent  or  attended  with 
signs  of  the  disorganization  of  the  ear. 

Duration  from  twelve  to  fourteen  days. 

Relapses  are  rare. 
The  blood  is  never  fibrinous. 
There  are  no  inflammatory  lesions  what- 
ever. 


Mortality  from  eight  to  forty  per  cent. 
Stille. 


Certain  cases  of  cerebro-spinal  fever  occurring  in  nervous  females  at  the 
close  of  epidemics,  or  sporadically,  have  presented  a  delirium  so  peculiar 
and  an  array  of  symptoms  so  little  characteristic,  that  they  have  been 
looked  upon  as  the  manifestations  of  hysteria.  It  is  to  be  hoped  that  a 
period  has  been  reached  in  the  progress  of  medicine,  in  which  such  an 
error  can  no  longer  arise  —  a  period  in  which  this  term  shall  be  used 
with  a  degree  of  circumspection  proportionate  to  the  vagueness  of  its 
meaning.  The  use  of  the  thermometer  will  clear  up  any  uncertainty 
of  diagnosis  between  this  fever  and  most  cases  of  functional  distur- 
bance of  the  nervous  system. 

Prognosis  and  Mortality. 


The  course  of  the  disease  is  very  variable.  In  individual  cases  the 
prognosis  can  never  be  made  with  certainty.  The  abortive  cases  and 
those  of  the  fulminant  variety  run  the  most  rapid  course.  Hirsch  has 
emphasized  the  fact  that  certain  cases,  whicli   at  the   onset  present   the 


98  THE    CONTINUED    FEVERS. 

symptoms  of  cerebro-spinal  fever,  promptly  recover  after  an  illness  of  a 
few  liours,  whicli  terminates  in  free  sweating.  The  most  intense  cases, 
on  the  other  hand,  prove  fatal  in  a  few  hours — as  few  as  five,  and  constantly 
as  early  as  the  second  or  third  day.  The  course  of  the  moderately  seveie 
cases  continues  one  or  two  weeks,  to  the  beginning  of  convalescence,  but 
it  in  other  cases  extends  over  months.  Sad  examples  of  the  ravages  of 
the  disease  are  to  be  encountered  after  every  epidemic.  In  the  fulmi- 
nant cases  death  is  by  far  the  most  common  termination;  in  cases  of  aver- 
age severity  it  is  still  frequent,  and  it  not  seldom  occurs  in  cases  that  have 
run  an  apparently  mild  course,  in  consequence  of  complications  or  se- 
quels. The  first  week  is  the  time  of  greatest  danger;  if  the  patient 
survive  that,  hope  of  his  recovery  may  be  entertained.  The  symptoms 
that  render  the  prognosis  unfavorable  are:  a  very  high  degree  of  excite- 
ment, the  early  appearance  of  depression,  return  of  the  vomiting,  intense 
headache,  continuous  coma,  recurring  convulsions,  and  irregular  respi- 
ration. 

In  cases  of  average  severity,  and  in  mild  cases,  a  guardedly  favorable 
prognosis  may  be  based  upon  the  uniform  gradual  amelioration  of  all  the 
symptoms  within  the  first  or  second  week,  and  the  establishment  of  con- 
valescence without  the  occurrence  of  grave  complications  or  sequels.  It 
is  to  be  borne  in  mind  that  relapses  are  not  infrequent,  and  that  they  are 
often  fatal. 

The  high  death-rate  that  attends  cerebro-spinal  fever  places  it  among 
the  most  dreaded  of  epidemic  diseases.  The  mortality  varies  greatly  in 
different  epidemics;  in  the  mildest,  it  is  about  thirty  per  cent.,  in  the  most 
severe,  seventy-five  per  cent.  The  average  may  be  stated  at  about  forty 
per  cent,  A  comparison  of  the  statistics  of  the  epidemics  of  the  early  and 
middle  periods  of  the  century  with  that  of  those  that  have  prevailed  within 
the  last  two  decades,  suggests  the  probability  of  a  gradual  diminution  of 
the  violence  of  the  disease.  This  difference  in  the  death-rate  is,  however, 
without  doubt  due  in  part  to  the  fact  that  the  energetic  depletory  meas- 
ures of  treatment  formerly  extensively  in  vogue  are  now  wholly  aban- 
doned. 

Mode  of  death. — Death  occurs  in  a  majority  of  cases  by  failure  of  the 
respiratory  nerve-centres,  in  some  instances  from  asthenia,  and  in  the 
fulminant  variety  probably  from  necrsemia. 

Treatment, 

Our  ignorance  of  the  precise  etiological  conditions  of  the  disease, 
limits  prophylaxis  to  general  sanitary  measures  for  the  purification  of 
houses  and  localities,  and  attention  to  personal  hygiene.  This,  as  all  epi- 
demic diseases,  assumes,  as  a  rule,  its  worst  form,  and  numbers  the  most 
victims,  where  anti-hygienic   conditions  most  abound.      Attention  to  the 


CEREBROSPINAL    FEVER.  99 

cleanliness  of  streets  and  dwelling-places,  to  the  condition  of  drainage  and 
sewerage,  the  prompt  removal  of  accumulations  of  refuse  matter,  and  the 
avoidance  of  overcrowding,  cannot  fail  to  diminish  the  severity  and  mor- 
tality of  the  disease. 

The  evidence  that  the  fever-poison,  in  some  instances,  spreads  among 
the  different  members  of  a  household,  either  from  the  individual  first  at- 
tacked, from  his  personal  effects,  or  in  consequence  of  some  unknown  fav- 
oi'ing  condition  of  the  surroundings,  renders  it  advisable  that,  where  prac- 
ticable, the  dwellings  in  which  the  disease  has  made  its  appearance,  should 
be  abandoned  until  after  the  close  of  the  epidemic  (Ziemssen).  It  is  rec- 
ommended that  all  the  linen  and  other  articles  used  by  the  patients  should 
be  carefully  disinfected,  or  perhaps  burned. 

The  use  of  plain  and  wholesome  food,  the  avoidance  of  unusual  fatigue, 
both  bodily  and  mental,  and  of  excesses  of  every  kind,  are  important. 
Moderate  exercise,  quiet,  and  regular  living,  may  afford  some,  but  by  no 
means  complete  security  during  the  epidemic. 

Nervous  persons  and  those  in  feeble  health,  should,  when  possible, 
leave  an  infected  district  upon  the  outbreak  of  the  disease. 

The  treatment  of  the  disease  has  been  almost  as  various  as  its  various 
physiognomy.  In  different  epidemics  and  at  different  periods,  divergent 
and  even  opposite  methods  of  treatment  have  been  adopted.  On  the 
one  hand,  a  vigorous  tonic  and  stimulant  plan  has  been  pursued  by 
tl?ose  to  whom  the  disease  has  presented,  in  an  extreme  degree  from  the 
onset,  the  symptoms  of  depression;  again,  the  urgent  symptoms  of  an 
intense  inflammatory  process  localized  in  the  membranes  of  the  brain  and 
spinal  cord,  have  seemed  to  some  to  indicate  the  energetic  use  of  deple- 
tory and  other  antiphlogistic  remedies,  including  the  administration  of 
mercurials,  while  others  have  been  content  with  a  modified  expectant  plan 
of  treatment,  in  which  a  careful  regimen  and  efforts  to  combat  the  symp- 
toms as  they  arise,  play  the  chief  part. 

In  the  present  state  of  knowledge,  it  is  impossible  to  decide  whether 
or  not  any  plan  of  treatment  yet  resorted  to  is  capable  of  so  affecting  the 
mortality  as  to  lower  the  death-rate  in  particular  epidemics,  while  there 
is  reason  to  believe  that  the  extreme  fatality  characterizing  some  of  the 
older  epidemics  has  been  in  part  due  to  the  repeated  and  copious  blood- 
lettings, and  other  depressing  measures  entering  into  the  treatment.  The 
difEculties  connected  with  the  consideration  of  the  treatment  of  this  dis- 
ease are  partly  inherent  to  the  subject  of  the  treatment  of  the  infectious 
diseases  in  general,  in  which,  the  cause  being  beyond  our  reach  and  its 
nature  unknown,  we  are  compelled  to  direct  our  therapeutic  efforts  alone 
against  the  consequences  of  its  action.  They  are,  however,  in  a  much 
greater  degree  dependent  upon  the  variable  and  diverse  forms  in  which 
this  disease  presents  itself.  Efforts  to  deduce,  from  statistics,  conclusions 
in  regard  to  the  success  of  different  modes  of  treatment  in  an  epidemic 


100  THE  CONTINUED  FEVERS. 

disease  in  which  the  mortality  ranges  between  thirty  and  seventy-five  per 
cent.,  must  yield  unsatisfactory,  if  not  fallacious  results,  Tt  is  not  only 
impossible  to  compare  the  results  of  treatment  in  different  epidemics,  but, 
from  the  capricious  nature  of  this  affection  and  its  various  manifestations, 
it  is  even  impossible  to  compare  cases  in  the  same  epidemic,  or  indeed,  to 
compare  the  cases  which  occur  during  the  rise,  the  maximum,  or  the  decline 
of  the  same  epidemic.  We  have  to  do  with  cases  of  this  fever  to  which 
the  term  average  cases  may  be  aptly  applied,  as  qualifying  the  intensity 
of  the  morbid  phenomena  and  the  rate  of  mortality  which  attends  them, 
M'hich  yet  differ  among  themselves  by  as  many  shades  as  there  can  be  va- 
rious combinations  of  the  infectious  or  blood  element  and  the  local  in- 
tlauunatory  element  which  jointly  underlie  its  manifestations.  Cases  are 
far  from  rare  in  which  the  attack  is  of  the  mildest  form,  only  to  be  recog- 
nized by  the  lurid  light  of  the  outbreak  in  which  they  occur,  cases  re- 
quiring no  treatment,  sometimes  not  even  compelling  the  subject  to  take 
to  his  bed.  In  strong  and  terrible  contrast  to  such  cases  are  those  in 
which,  in  the  midst  of  health,  W'hile  at  his  ordinary  occupation  or  on 
awaking  from  sleep,  the  patient  is  overwhelmed  by  the  poison  as  by  an 
avalanche,  and  passing  rapidly  from  agonizing  suffering  to  coma,  perishes- 
in  the  course  of  a  few  hours.  Here  the  brevity  of  the  course  and  the  na- 
ture of  the  lesions  alike  show  the  powerlessness  of  our  efforts  to  control 
the  attack.  Medicine,  with  all  its  resources,  is  neither  adequate  to  combat 
it,  nor  responsible  for  its  result.  As  Stille  has  said,  "'  the  first  symptoms 
of  the  disease  are  the  first  phenomena  of  death." 

We  are  driven  then,  in  estimating  the  results  of  treatment,  to  restrict 
our  observations  to  the  effect  of  remedies  upon  the  individual  patients,, 
the  immediate  influence  upon  their  symptoms,  both  objective  and  sub- 
jective, and  the  permanence  of  that  influence. 

A  judicious  troatment  must  be  based  upon  the  broad  general  princi- 
ples of  therapeutics. 

Antiphlogistic  treatment  would  seem  to  be  indicated  by  the  promi- 
nence of  the  symptoms  of  inflammatory  congestion  of  the  meninges  at  the 
onset  of  the  attack,  by  the  nature  of  the  lesions  constantly  found  after 
death,  and  by  the  relief  it  affords  in  a  large  proportion  of  the  cases.  But, 
in  view  of  the  infectious  character  of  the  cause  of  the  affection,  its  rapidly 
disintegrating  effect  upon  the  blood,  the  early  and  often  alarming  debility 
in  some  cases,  the  marked  depression  that  in  others  follows  the  active 
symptoms,  the  great  emaciation  and  the  tedious  convalescence,  measures 
of  depletion  must  be  employed  with  the  greatest  caution,  and  are  in  all 
but  the  sthenic  cases  contraindicated.  In  the  young,  and  particularly  in 
children,  the  abstraction  of  even  small  quantities  of  blood  is  liable  to  be 
followed  by  alarming  symptoms  of  depression.  Dr.  J.  Lewis  Smith  re- 
ports a  case  in  which  the  application  of  a  leech  to  each  temple  in  a  child 
aged  four  years  was  followed  bv  extreme  and  almost   fatal  exhaustion. 


CEREBRO-SPINAL    FEVER.  lUl 

General  bloodletting  is  in  no  case  admissible.  It  is  to  be  borne  in  uiiud 
that  the  pulse  is  almost  always,  even  from  the  onset,  such  as  would  contra- 
indicate  the  abstraction  of  blood,  and  if  the  urgency  of  the  symptoms  of 
the  local  inflammation  and  the  critical  state  of  the  patient  seem  to  call 
for  the  employment  of  energetic  measures,  the  clinical  history  of  the  dis- 
ease reminds  the  physician  that  a  no  less  marked  depression  is  speedily  to 
follow  and  calls  for  a  thoughtful  regard  for  the  future.  Even  in  tlio 
sthenic  cases  the  local  application  of  cut  cups  to  the  nape  of  the  neck  and 
along  the  spine  is  to  be  employed  with  caution.  Leeches  may  be  applied 
to  the  temples  and  in  the  neighborhood  of  the  mastoid  processes.  These 
measures  are  of  great  value  in  mitigating  the  headache  and  spinal  pains 
which  form  so  prominent  a  symptom  in  many  cases. 

If  such  local  abstractions  of  blood  be  contraindicated  by  the  state  of 
the  patient,  dry  cupping  may  be  emj^loyed  with  advantage. 

The  direct  application  of  cold  to  the  head  and  spine  by  means  of  ice, 
snow,  or  a  freezing  mixture  in  rubber  bags  made  for  the  purpose,  and 
to  be  had  at  the  apothecaries'  shops,  is  not  open  to  the  same  objections 
as  bloodletting,  and  at  the  same  time  is  attended  with  satisfactory  results 
as  regards  the  symptoms  of  inflammation.  If  the  bags  cannot  be  pro- 
cured, a  bladder  filled  with  cracked  ice  mixed  with  bran  may  be  substi- 
tuted. In  children  gentle  cold  affusions  may  be  practised.  The  applica- 
tion of  cold  by  these  means  is  in  most  cases  followed  by  very  marked 
mitigation  of  the  pains,  and  often  by  quietude  or  sleep.  It  should  be 
continued  as  long  as  the  patient  is  comfortable,  and  repeated  upon  the 
return  of  the  symptoms.  Patients  frequently  require  the  continuous  ap- 
plication for  hours  at  a  time.  A  hot  mustard  foot-bath,  or  a  general  hot 
bath,  38°— 39^  C.  (100.4°— 102.2**  F.),  should  be  employed  as  early  as  pos- 
sible, care  being  taken  that  the  strength  of  the  patient  be  in  no  wise 
taxed.  This  may  be  followed  by  gentle  frictions  with  some  stimulating- 
liniment,  or  with  oil  of  turpentine,  if  the  surface  be  cold  and  the  circu- 
lation depressed.  A  stimulating  enema  may  at  the  same  time  be  ad- 
ministered. The  patient  should  also  be  covered  with  warmed  blankets, 
and  artificial  heat  applied  to  his  sides,  thighs,  and  extremities.  In  all 
cases  it  is  well,  while  using  the  cold  to  the  head  and  spine,  to  counteract  its 
depressing  effect  by  the  application  of  moderate  heat  elsewhere.  This 
may  be  accomplished  by  means  of  hot  flannels,  bags  of  hot  sand  or  salt, 
bottles  filled  with  hot  water,  or  heated  billets  of  wood  well  wrapped  up. 
At  the  same  time,  if  necessary,  sinapisms  are  to  be  applied  to  the  ex- 
tremities and  the  prsecordium. 

Bartholow  holds  that  the  application  of  ice  to  the  head  and  spine  may 
do  mischief  by  the  depression  of  the  circulation  which  it  causes.  He  ad- 
vises, instead,  the  use  of  hot  water  applied  by  a  sponge  passed  over  tlio 
spine  every  two  or  three  hours.  The  best  modern  American  authorities 
agree  in  advising  the  continuous  use  of  external  heat,  to  anticipate  and 


1U2  THE  CONTINUED  FEVERS. 

counteract  the  early  depression  which  is  so  grave  an  element  of  the  dis- 
ease, a  practice  very  general  in  the  early  epidemics  in  this  country,  but 
for  a  long  time  strangely  overlooked  here,  and  altogether  neglected  abroad. 

Blisters  upon  the  occiput  and  upon  the  nape  of  the  neck  are  not  only 
to  be  advised  upon  theoretical  grounds,  but  they  are  of  great  practical 
value  in  relieving  pain  and  in  diminishing  delirium,  spasm,  and  coma. 
They  should  be  applied  early  in  the  course  of  the  disease. 

The  use  of  mercury,  except  at  the  onset  of  the  attack,  in  the  form  of  a 
dose  of  calomel  as  a  purgative,  is  to  be  discountenanced.  No  single  drug 
has  been  employed  to  a  greater  extent  than  mercur}'  in  the  treatment  of 
cerebro-spinal  fever,  but  almost  all  authorities  at  this  time  regard  with 
disfavor  the  employment  of  the  preparations  of  this  metal  for  its  sup- 
posed antiphlogistic  or  antiplastic  effect,  or  its  absorbent  effect  upon 
the  exudation.  Among  the  most  recent  German  writers,  Ziemssen,  how- 
ever, recommends  its  use  in  the  form  of  mercurial  ointment  or  calomel, 
"  for  the  purpose  of  preventing  the  extension  of  the  meningeal  inflamma- 
tion and  exudation."  He  employs  free  inunctions  and  the  internal  use 
of  calomel  "  in  almost  every  case,"  but  admits  that  when  used  in  connec- 
tion with  other  remedies,  it  is  difficult  to  ascertain  its  share  in  the  com- 
mon effect,  and  that  even  when  used  alone  its  efficacy  is  by  no  means 
clearly  established. 

The  antipyretic  treatment  by  cold  baths  and  enormous  doses  of  quinia, 
as  practised  by  the  Germans  in  diseases  attended  by  hypyrexia,  can  be 
rarely  necessary,  for  the  reasons  that  in  most  cases  the  fever  is  moderate, 
and  in  those  cases  characterized  by  an  excessively  high  temperature,  the 
fatal  event  is  due  to  other  causes  than  the  fever.  Quinia  has  no  control 
over  the  intermittent  variety  of  the  disease.  In  the  report  of  the  Committee 
of  the  American  Medical  Association,  written  by  Dr.  Levick,  above 
quoted,  the  use  of  quinia  in  large  doses,  at  the  very  heginning  of  the  dis- 
ease, is  favorably  spoken  of;  but  its  administration  in  the  later  period, 
Avhen  the  phenomena  all  point  to  intra-cranial  exudation,  is  said  to  be  of 
no  use  and  liable  to  prove  even  hurtful,  except  in  small  doses  as  a  tonic 
to  an  enfeebled  system. 

The  statement  that  this  drug  has  appeared  to  abort  the  disease  in  some 
instances  is  not  borne  out  by  sufficient  evidence. 

There  is  no  abortive  treatment. 

Opium,  by  the  concurrent  testimony  of  observers  in  all  countries,  now 
holds  the  highest  place  in  the  treatment  of  this  disease.  It  was  used  in 
this  country  in  the  early  part  of  this  century,  adopted  as  a  treatment  in 
France  at  a  later  period,  and  has  recently  found  favor  in  the  eyes  of  the 
physicians  of  Germany.  Ziemssen  says  of  morphia,  that  it  '*  may  he  re- 
garded as  one  of  the  most  indispensable  remedies  in  the  treatment  of  epi- 
demic meningitis." 

All  the  distressing  symptoms,  the  headache  and  spinal  pains,  restless- 


CEREBRO-SPINAL    FEVER.  103 

ness,  the  spasm,  the  hyperaesthesia,  and  the  inability  to  sleep,  call  for  the 
administration  of  this  drug.  At  the  same  time  our  knowledge  of  the 
nature  of  the  lesions  suggests  its  use.  Opium  slows  the  heart  and  in- 
creases arterial  tension.  It  is  to  be  employed  at  the  earliest  moment 
possible,  and  in  full  doses.  By  this  means  we  may  anticipate  the  occur- 
rence of  exudation,  or  limit  it. 

Experience  has  shown  that  a  remarkable  tolerance  for  this  drug  exists 
in  most  cases  of  cerebro-spinal  fever.  Some  of  the  older  physicians  gave 
large  doses.  Strong '  in  one  case  "  gave  sixty  drops  of  laudanum  every 
hour  till  half  a  fluid  ounce  was  taken.  The  whole  of  it  was  retained,  and 
it  subdued  the  excitement  and  relieved  the  pain,  but  produced  no  sleepi- 
ness or  other  apparent  effect  of  opium.  Others  among  the  early  American 
writers  gave  enormous  doses,  16  c.c.  or  half  an  ounce  of  the  tincture,  or 
from  2 — 4  grammes  (thirty  to  sixty  grains)  in  substance,  in  the  course  of 
twelve  hours,  being  necessary  to  control  the  urgent  symptoms.  Such 
cases  recovered. 

Chauffard,"  to  whom  Hirsch  erroneously  ascribes  the  first  advocacy  of 
the  opium  treatment,  gave  it  in  doses  of  from  0.2 — 1.0  gramme  (three  to 
fifteen  grains).  Boudin  '  frequently  gave  up  to  0.45 — 1.0  gramme  (seven 
to  fifteen  grains)  at  a  single  dose  at  the  commencement  of  the  attack,  and 
afterward  0.065 — 0.13  gramme  (one  to  two  grains)  every  half-hour.  As 
soon  as  the  symptoms  abated  or  the  patient  became  drowsy,  the  dose  was 
diminished.  Stille  gave  0.065  gramme  (one  grain)  every  hour  in  very  se- 
vere cases,  and  every  two  hours  in  moderately  severe  cases  without  nar- 
cotism, or  even  an  approach  to  that  condition.  He  adds  that  "  under  the 
influence  of  the  medicine,  the  pain  and  spasm  subsided,  the  skin  grew 
Avarmer  and  the  pulse  fuller,  and  the  entire  condition  of  the  patient  more 
hopeful." 

The  remedy  must  be  given  for  its  effect,  and  the  quantity  necessary  is 
to  be  prescribed.  Its  action  is  to  be  carefully  watched.  Its  greatest 
usefulness  is  to  be  reached  only  by  its  administration  early  in  the  course 
of  the  disease.  After  the  symptoms  indicative  of  effusion  appear,  it 
must  be  given  in  lessened  doses,  and  its  utility  is  greatly  diminished.  It 
is  among  the  most  notable  facts  respecting  the  use  of  opium  in  this  dis- 
ease, that  the  early  American  physicians  did  not  hesitate  to  employ  it 
when  coma,  a  condition  usually  thought  to  preclude  the  use  of  narcotics, 
threatened,  nay,  Strong  and  others  have  recorded  their  opinion  that  it  is 
a  powerful  agent  in  removing  such  comas  as  are  not  "  absolutely  irrecov- 
erable." 

When  the  condition  of  the  patient  is  such  as  to  render  its  administra- 


'  Quoted  by  Stille. 

•'  Revue  medicale,  LXXXVI.   1842. 

"  Histoire  typhus  cerebro-spinal,  par  C.  M.  Boudin.     Paris,  1854. 


104  THE    CONTINUED    FEVERS. 

tion  by  tlie  mouth  impracticable,  or  when  tlie  repeated  vomiting  pre- 
vents its  absorption,  it  may  be  given  in  the  form  of  enemata  or  supposi- 
tories, by  the  rectum,  or  one  of  the  morphia  salts  may  be  substituted  in 
hypodermic  injections.  The  latter  is  in  most  cases  the  best  plan  of 
treatment. 

In  view  of  the  fact  that  children  are  peculiarly  susceptible  to  the 
action  of  this  drug,  the  dose  must  be  regulated  with  caution.  A  boy 
aged  six,  under  the  care  of  Dr.  J.  Lewis  Smith,  was  quieted  by  the 
subcutaneous  injection  of  ^'^  of  a  grain  (0-002  gramme)  of  morphia  sul- 
phate. 

Ergot  and  belladonna  have  been  used  upon  theoretical  grounds,  on  ac- 
count of  their  influence  in  diminishing  vascularity  of  the  nervous  centres, 
but  the  evidence  of  their  value  is  not  satisfactory.  Rosenthal '  urges 
great  caution  in  the  administration  of  belladonna  and  in  the  hypodermic 
use  of  atropine. 

Cannabis  indica,  the  fluid  extract  of  gelsetnium  (Bartholow),  zinc 
oxide,  large  doses  of  chloral  hydrate  and  inhalations  of  chloroform,  have 
been  employed  in  the  management  of  the  excitement.  Chloral  is  to  be 
emphatically  condemned  in  the  treatment  of  a  disease  attended  with  vomit- 
inar  so  continued  as  often  to  interfere  with  the  assimilation  of  food,  and 
characterized  by  a  tendency  to  extreme  exhaustion ;  and  chloroform  inhala- 
tions, when  from  the  outset  we  often  have  to  do  with  a  feeble  and  irregu- 
lar action  of  the  heart,  showing  itself  in  extreme  weakness  and  irregularity 
of  the  pulse,  and  a  tendency  to  syncope  upon  assuming  the  upright  pos- 
ture; of  the  others  it  may  be  said  that  they  are  useful  auxiliaries  to 
treatment,  but  that  they  do  not  in  severe  cases  constitute  an  efficient 
medication. 

The  last  remark  holds  true  also  of  the  potassium  bromide,  a  remedy, 
which  has,  however,  great  value  in  the  treatment  of  mild  cases,  and  in  the 
treatment  of  children.  It  may  be  advantageously  combined  with  opium 
or  morphia. 

In  cases  of  extreme  urgency,  the  inhalation  of  Squibb's  ether  may  be 
resorted  to  for  the  purpose  of  securing  temporary  relief  from  the  tortur- 
ing pain,  the  jactitation,  and  the  spasm. 

Upon  the  approach  of  depression,  excitants  and  stimulants  are  to  be 
resorted  to.  Among  the  more  useful  are  aminonium  carbonate,  spirits  of 
chloroform,  turpentine,  and  the  preparations  of  alcohol.  Cold  affusion, 
practised  several  times  a  day,  is  recommended  by  German  writers.  It  is 
a  remedy  scarcely  likely  to  be  widely  used  in  this  country.  Quinine  may 
be  given  in  moderate  doses. 

Al'^oholic  stimulants  are  required  at  some  time  in  the  course  of  the  ma- 


'  Rosenthal  :  Diseases  of  the  Nervous  System.      Aqaerioan  edition.     New  York, 
1879. 


CEREBROSPINAL    FEVER.  105 

joiity  of  cases.  Their  use  as  a  remedy  in  the  treatment  of  this  fever,  in- 
dependently of  the  indications  which  govern  their  use  in  the  general 
management  of  diseases,  has  not  been  followed  by  satisfactory  results, 
n^hey  are  to  be  promptly  resorted  to  when  symptoms  of  depression  of  the 
nervous  system  show  themselves,  whether  it  be  at  the  onset  of  the  attack 
or  later  in  the  progress  of  the  case.  Their  amount  must  be  regulated  by 
the  effect  which  they  produce.  The  pulse  and  the  first  sound  of  the 
heart  are  the  best  guides.  If  the  pulse,  after  the  free  administration  of 
alcohol  becomes  less  frequent,  stronger  and  fuller,  and  the  first  sound 
more  distinct,  it  is  beneficial;  but  if  the  pulse  increases  in  frequency,  the 
heart's  action  being  excited,  the  tongue  grows  dry,  and  the  excitement 
augments,  the  alcohol  must  be  given  in  decreased  doses  or  abandoned 
altogether.  If  the  need  be  urgent,  and  the  patient  unable  to  swallow, 
brand}'  should  be  given  hypodermically. 

During  the  convalescence  the  vegetable  tonics  and  iron  are  to  be 
employed.  Arsenic,  and  especially  potassium  arsenite,  are  also  useful  at 
this  period.  The  latter  has  been  praised  as  a  remedy  of  value  in  the  man- 
agement of  the  acute  disease.  These  praises  are  unfounded.  Cod-liver 
oil  is  of  use,  and  in  proper  cases  potassium  iodide  is  of  proved  service 
in  promoting  the  resorption  of  the  exudation.  Its  use  should  be  long- 
continued,  and  at  the  same  time  flying  blisters,  daily  hot  affusions,  and, 
after  all  acute  symptoms  wholly  cease,  mild  continuous  currents  should 
be  employed. 

The  potassium  iodide  is  not  of  use  in  the  treatment  of  cerebro-spinal 
fever  during  its  acute  course.  Ziemssen  states  that  he  has  not  found  it 
of  the  slightest  benefit  in  the  chronic  hydrocephalus  occurring  as  a  sequel 
— a  result  which  the  natux'e  of  the  lesions  in  that  affection  would  lead  us 
to  expect. 

Diet. — A  generous  alimentation  is  to  be  given  from  the  beginning  of 
the  sickness.  During  the  continuance  of  the  febrile  phenomena,  milk, 
eggs,  meat-juice  and  broths  should  be  given  at  regular  intervals,  and 
continued  in  severe  cases  during  the  night.  If  food  cannot  be  taken 
by  the  mouth,  an  attempt  should  be  made  to  administer  nutritious 
enemata. 

As  soon  as  he  is  able,  the  patient  should  be  allowed  an  abundance  of 
solid  food.  The  appetite  is  often  excellent,  even  in  the  early  days  of  con- 
valescence. 

When  there  is  thirst,  the  desire  for  water  must  be  freely  gratified. 
This  symptom  is  often  very  distressing. 

Constipation  may  be  relieved  by  a  dose  of  calomel  with  or  without 
jalap,  by  other  simple  drugs,  or  by  enemata.  Neither  constipation  nor 
diarrhoea  are,  as  a  rule,  difficult  of  relief. 

When  there  is  much  prostration,  and,  indeed,  in  most  cases,  the  pa- 


106  THE  CONTINUED  FEVERS. 

tient  should  be  guarded  against  assuming  the  erect  posture,  or,  in 
truth,  against  ev'en  sitting  upright  in  bed,  on  account  of  the  danger  of 
syncope. 

The  room  should  be  darkened,  and  all  noises  and  other  disturbing  in- 
fluences avoided. 

Delirium,  spasm,  and  irritability  of  the  stomach,  too  often,  in  the  se- 
vere cases,  render  the  administration  of  medicine  and  food  impracticable. 


IV. 

ENTERIC  OR  TYPHOID  FEVER. 

Definition. — An  acute,  endemic,  febrile  disease,  of  long  duration,  due  to 
a  poisonous  principle  associated  with  certain  forms  of  decomposinar 
animal  matter.  It  is  characterized  by  a  gradual  and  often  insidious 
commencement  ;  dull  headache,  followed  by  stupor  and  delirium  ; 
a  red  tongue,  occasionally  becoming  dry  and  brown  ;  in  most  cases 
tympany,  abdominal  tenderness,  and  diarrhoea  ;  an  eruption  of  iso- 
lated, slightly  elevated  rose-colored  spots,  disappearing  on  pressure 
and  developed  in  successive  crops  ;  increased  splenic  dulness  ;  epis- 
taxis  ;  late  prostration  and  tardy  convalescence.  After  death,  con- 
stant lesions  of  the  solitary  and  agminate  glands  of  the  ileum,  with 
enlargement  of  the  mesenteric  glands  and  of  the  spleen,  are  found. 

Synonyms. — Typhus  nervosus;  Typhus  mitior;  Abdominal  typhus;  Darm- 
typhus;  Synochus  and  typhus  with  abdominal  affection;  Typhus  gan- 
gliaris  vel  entericus;  Ileo-typhus;  Typhia;  Typhus;  Fievre  typhoide  ; 
Typhoid  fever  ;  Mild  typhoid  fever. 

Febris  non-pestilens  ;  Endemic  fever;  Autumnal  or  fall  fever. 

Remittent  fever  ;  Infantile  remittent  fever. 

Febris  lenta;  Slow  or  lent  fever;  Febris  chronica;  Chronic  con- 
tinued fever  ;  Fievre  continue. 

Nervous  fever;  Slow  nervous  fever;  Irregular  low  nervous  fever; 
Low  fever  ;  Nervenfieber;  Fievre  nerveuse. 

Febris  putrida  ;  Febris  putrida  nervosa;  Sepimia  ;  Entente  septi- 
cemique. 

Febris  hectica;  Infantile  hectic  fever. 

Febris  gastrica;  Febris  acuta  stomachica  aut  intestinalis;  Febris 
glutinosa  gastrica;  Febris  gastrica  acuta;  Gastrisches  Fieber;  Fievre 
gastrique;  Epidemic  gastric  fever;  Gastric  fever;  Febris  biliosa;  Bil- 
ious fever;  Bilious  continued  fever  ;  Febris  biliosa  putrida  ;  Synochus 
biliosa  ;  Bilio-gastric  fever  ;  Gastro-bilious  fever. 

Febris  colliquativa  ;  Febris  stercoralis  ;  Febris  mucosa  ;  Febris 
pituitosa;  Morbus  bilioso-mucosus;  Febris  pituitosa  nervosa;  Schleim- 
Fieber;  Fievre  muqueuse  ;  Mucous  or  pituitous  fever. 

Febris  mesenterica  maligna  ;    Febris  intestinalis  vel  mesenterica; 


108  THE    CONTINUED    FEVERS. 


Febris  mesenterlca  acuta  ;  Enteritic  fever  ;  Gastro-enterite  ;  Entero- 
mesenteric  fever  ;  Dothienenterie  ;  Muco-enteritis  ;  Fever  with  affec 
lion  of  the  abdomen  ;  Fever  with  ulceration  of  the  intestines  ;  Gas- 
tro-enteric  and  gastro-splenic  fever  ;  Enterite  foUiculeuse  ;  Enteric 
fever  ;  Febris  tympanica  ;  Intestinal  fever. 

Night-soil  fever  ;   Cesspool  fever  ;  Pythogenic  fever. 

Rock  fever  ;  Mountain  fever. 

The  above  long  list  of  the  terms  under  which  this  fever  has  been  de- 
scribed at  various  periods  and  by  many  different  authors,  is  taken,  with] 
few  exceptions,  from  Dr.  Murchison's  great  work  upon  the  "Continued 
Fevers  of  Great  Britain."  They  are  variously  derived  from  its  supposed 
relationship  to  typhus,  its  mode  of  prevalence,  its  remittent  character,  its 
long  duration,  its  supposed  nervous  origin,  the  occurrence  of  septic  or 
putrid  symptoms,  its  hectic  phenomena,  the  presence  of  symptoms  denot- 
ing disturbance  of  the  stomach  and  liver,  the  intestinal  symptoms,  the 
morbid  anatomy,  its  mode  of  origin,  and  localities  in  which  it  has  pre- 
vailed. The  term  "  abdominal  typhus  "  and  its  equivalents,  in  general 
use  in  Germany  and  elsewhere  upon  the  Continent,  are  open  to  the  ob- 
jection that  they  suggest  a  relationship  with  typhus  that  is  now  acknow- 
ledged on  all  sides  not  to  exist.  They  are,  in  fact,  due  to  the  opinion 
formerly  generally  entertained,  that  there  existed  between  the  two  affec- 
tions an  essential  pathological  identity — that  they  were,  in  fact,  two  varie- 
ties of  a  single  species  of  fever.  This  opinion  is  no  longer  tenable. 
"  Typhoid,"  suggested  by  Louis  in  1829,  is  open  to  the  same  objection, 
since  the  labors  of  pathology  during  the  past  half-century  have  shown 
with  increasing  clearness,  not  that  the  fever  in  question  is  like  typhus, 
but  that  it  is  unlike  it.  This  term  has,  however  the  sanction  of  very  gen- 
eral acceptance  in  France  and  among  English-speaking  physicians.  The 
strongest  objection  to  its  use  for  any  purpose  whatever,  lies  in  its  com- 
mon employment  as  an  adjective  to  designate  a  condition  or  group  of 
symptoms  that  may  appear  in  the  course  of  any  acute  disease — a  use  that 
has  given  rise  to  endless  confusion  of  thought  and  vagueness  of  descrip- 
tion. The  term  "  e«^e?7'c /ewer,"  proposed  by  the  late  Professor  George 
B.  Wood,  possesses  the  advantage  of  designating  at  the  same  time  the 
.anatomical  seat  of  the  constant  primary  lesion,  and,  by  a  now  accepted 
usage  of  the  word  fever  in  combinations  of  this  kind,  the  infectious  na- 
ture of  the  disease.  It  was  adopted  in  the  "  Nomenclature  of  Diseases," 
in  18G9. 

Historical  Sketch. 

Enteric  fever  has  been  separated  from  the  general  group  of  the  fevers 
as  a  substantive  disease  only  in  the  present  century.  It  is  probable, 
jiowever,  that  it   has  come  down  to  us  from   a  roniote  antiquity.     The 


1 


ENTET^IC    OR    TYPHOID    FEVEPw.  10^ 

description  of  a  continued  fever  mentioned  by  Hippocrates  as  prevalent 
in  the  autumn,  and  characterized  by  diarrhoea,  bilious  vomiting,  tympany, 
abdominal  pain,  red  rashes,  bleeding  at  the  nose,  sleeplessness  or  a 
tendency  to  coma,  delirium  and  subsultus,  irregular  remissions,  a  long 
duration  and  great  emaciation,  doubtless  refers  to  tliis  disease.  It 
has  been  thought  likewise  that  Galen  described  it  under  the  name  of 
"  hem.Uritoeus^''  a  name  applied  to  a  disease  resulting  from  the  grafting 
of  a  tertian  upon  a  quotidian  intermittent.  Dr.  Murchison  thinks  there 
is  little  doubt  that  the  ^^febrls  semitertiana''''  of  the  writers  of  the  seven- 
teenth century  was  true  enteric  fever.  Spigelius  (1684),  Panarolus 
(1654)  and  Baglivi  (1696)  in  Italy,  Thomas  Bartholin  (1641)  in  Copenha- 
gen, and  Willis  (1659)  and  Sydenham  (1685)  in  England,  recorded  their 
observations  of  cases  of  fever,  which  both  in  the  symptoms  and  the  post- 
mortem appearances  corresponded  with  enteric  fever  as  we  know  it. 

During  the  eighteenth  century  many  accounts  of»  enteric  fever  were 
published,  and  the  difference  between  its  symptoms  and  those  of  typhus, 
as  well  as  the  prominence  of  the  intestinal  lesion,  attracted  the  growing 
attention  of  British  and  Continental  physicians. 

Strother  (1739)  distinguished  the  epidemic  fever  of  1727-29  in  Lon- 
don, which  we  know  to  have  been  typhus,  from  the  sloio  fevers,  one  variety 
of  which,  "  the  lent  fever,  is  a  symptomatical  fever,  arising  from  an  in- 
flammation, or  an  ulcer,  fixed  on  some  of  the  bowels." 

Gilchrist  (1734),  Languish  (1735),  and  Huxham  (1739),  called  atten- 
tion to  the  differences  between  the  Nervous  Fever,  or  the  Slow  JVervous 
Fever,  and  the  Malignant  Continued  Fever,  or  Putrid  Malignant  Pete- 
chial Fever,  generally  prevalent  in  England  and  Scotland. 

Sir  Richard  Manningham  (1746)  published  an  account  of  the  "  Symp- 
toms, Nature,  etc.,  of  the  Febricula  or  Little  Fever."  This  fever  was 
described  as  of  insidious  origin,  and  apt  in  the  beginning  to  be  disre- 
garded; but  at  length  conspicuous  and  very  terrible  symptoms  arose,  upon 
which  the  physician  was  sent  for  in  the  greatest  haste,  and  "  the  little,, 
neglected  fever  proves  of  very  difficult  and  uncertain  cure,  and  too  often 
becomes  fatal  in  the  end."  Its  prominent  symptoms  were  a  red  tongue, 
often  dry,  abdominal  pains,  diarrhoea,  hemorrhage,  a  quick  pulse,  loss  of 
memory,  and  sometimes  slight  delirium.  It  was  known  popularly  as  the 
Nervous  or  Hysteric  Fever,  Loic  Contimicd  Fever,  Fever  on  the  Spirits, 
Vapors,  Hypo  or  Spleen. 

Others,  at  this  period  and  later,  regarded  the  febris  nervosa  as  a  very 
different  disease  from  the  febris  carceruni,  and  in  particular,  Willan 
(1799)  "observed  that  Cullen  had  improperly  comprised  under  the  term 
typhus  the  slow  or  nervous  fever  described  by  Gilchrist  and  Huxham, 
which  may  rather  be  considered  as  a  species  of  hectic,  and  is  not  received 
by  infection."  It  is  at  this  point  worthy  of  remark  that  the  term  hectic, 
thus  employed  by  Willan,  seems  singularly  appropriate  in  view  of  the 


110  THE    CONTINUED    FEVEKS. 

modern  doctrine  of  a  primary  and  secondary  or  septic  fever  in  the  course 
of  the  disease,  and  that  Matiningham's  observation  that  the  "  little,  neg- 
lected fever  "  might  prove  at  length  "  very  difficult  and  uncertain  of  cure," 
and  "  often  fatal  in  the  end,"  is  in  full  accord  with  the  now  well-known 
fact  that  cases  untreated  in  the  beginning  are  apt  to  be  very  serious  and 
often  fatal. 

The  Irish  physicians  of  the  last  quarter  of  the  eighteenth  century  also 
make  frequent  mention  of  the  febris  nervosa,  a  continued  fever  of  three  or 
four  weeks'  duration,  more  frequently  occurring  in  the  autumn,  and  at- 
tended by  diarrhoea  and  by  hemorrhages. 

Upon  the  continent,  during  the  same  period,  many  accounts  of  enteric 
fever  were  published.  De  Haen,  of  Vienna  (1760),  describes  it  as  Miliary 
Fever ;  Stoll  (1785)  as  the  Pltuitous  or  the  Slow  Nervous  Fever  ;  others 
as  Febris  Intestinalis. 

About  the  beginning  of  the  present  century  the  pathologists  of 
France  began  to  study  the  pathological  anatomy  of  fever  with  great 
earnestness.  Prost  (1804)  announced  that  mucous,  gastric,  ataxic  and 
adynamic  fevers  have  their  seat  in  the  mucous  membrane  of  the  intestine. 
Broussais  (181 G)  advocated  similar  views.  He  regarded  it  as  useless  to 
distinguish  between  the  ulcerations  found  in  fever  and  frequently  having 
their  seat  in  the  intestinal  glands,  and  inflammations  of  other  portions  of 
the  intestines.  He  believed  that  the  symptoms  were  due  to  the  inflamma- 
tion, gastro-enterlte,  and  upon  this  opinion  he  based  his  advocacy  of 
copious  depletion. 

Petit  and  Serres  (1813)  described  enteric  fever  as  the  Fievre  entero- 
i/tesentei'ique.  They  called  attention  to  the  fact  that  the  disease  differed 
from  ordinary  enteritis,  and  were  the  first  to  look  upon  it  as  specific. 
They  regarded  the  lesions  as  the  result  of  the  introduction  of  a  poison, 
and  as  of  an  eruptive  nature,  like  the  pustules  of  variola,  failing,  how- 
ever, to  localize  the  processes  of  the  disease  in  the  solitary  and  agminate 
glands.  To  these  observers  is  due  the  credit  of  having  first  pointed  out 
the  fact  that  the  intestinal  lesions  are  limited  to  the  ileum,  and  principally 
to  its  lower  parts. 

In  1818,  Bretonneau  began  at  Tours  the  series  of  anatomical  re- 
searches that  enabled  him  to  prove  that  the  solitary  and  agminate  glands 
of  the  ileum  are  always  implicated  in  the  processes  of  this  fever,  and 
that  it  differs  essentially  from  all  other  inflammations  of  the  bowels.  He 
maintained  that  the  disease  was  due  to  a  poison  communicable  from  the 
sick  to  the  healthy,  and  regarded  the  intestinal  lesion  as  analogous  to  the 
cutaneous  eruptions  of  the  exanthemata.  He  pointed  out  the  fact  that 
the  severity  of  the  general  symptoms  bears  no  relation  to  the  intensity  of 
the  eruption.  He  named  the  disease  dothieu enteric,  or  dothienenterite 
{^odvqv,  a  small  abscess,  boil,  and  evrcpov,  intestine),  the  "  Dothinenteria" 
of  the  translators  of  Trousseau.     These  views  were  made  known  in  Paris 


ENTERIC  OR  TYPHOID  FEVER.  Ill 

in  1820,  but  were  first  published  by  Landini '  and  Trousseau.'  pupils  of 
Bretonneau  in  1826,  and  by  Bretonneau '  himself  in  1827. 

Louis's  elaborate  work,  "  Recherches  sur  la  maladie  connue  sous  les 
noms  de  gastro-enterite,  fievre  putride,  adynamique,"  etc.,  appeared  in 
1829.  It  not  only  contained  an  admirable  and  exhaustive  description  of 
the  fever,  but  also  an  analysis  of  the  symptoms  and  pathological  phe- 
nomena so  accurate  and  full,  to  use  the  words  of  Gerhard,  "  as  to  surpass 
any  other  description  of  individual  diseases."  Enteric  fever  was  so  well 
studied  by  Louis,  and  its  symptoms  so  well  set  forth  in  this  work,  that  it 
served  from  that  time  as  a  standard  of  comparison  for  other  affections 
less  thoroughly  understood.  It  may  be  said  then,  with  truth,  that  the  ap- 
pearance of  this  work  marked  an  important  epoch  in  the  history  of  the 
continued  fevers.  Louis  gave  to  the  disease  the  nsune^fi^vre  typho'ide^ 
which  was  a  few  years  later  adopted  by  Chomel  (1834),  and  soon  passed 
into  general  use  in  France  and  among  English-speaking  physicians. 

At  the  period  of  these  investigations  into  its  pathology,  enteric  fever 
was  very  prevalent  in  Paris  and  elsewhere  in  France.  There  was,  ac- 
cordingly, abundant  opportunity  for  its  clinical  and  anatomical  study. 
Typhus  fever  was,  on  the  other  hand,  unknown.  An  epidemic  of  typhus, 
brouglit  back  by  the  retreating  armies  of  Napoleon  after  the  disastrous 
campaigns  of  1813-14,  in  Germany  and  Eastern  France,  had  prevailed 
extensively  in  Paris  and  elsewhere  in  the  large  cities,  and  had  been  every- 
where extremely  fatal.  But,  from  the  date  of  the  subsidence  of  this  out- 
break, typhus  had  not  occurred  within  the  borders  of  France,  and  was,  to 
the  French  physicians  of  the  time  of  Louis  and  Chomel,  practically  un- 
known. These  observers  therefore  fell  into  the  error  of  regarding  the  con- 
tagious fever  of  camps  and  armies,  and  of  the  British  writers,  as  identical 
with  the  prevalent  fever  known  to  them  as  dothienenterie  or  typho'lde. 

At  the  same  time  English  physicians  were  not  idle  in  the  study  of  the 
pathology  of  fever.  As  a  result  of  their  investigations,  however,  it  was 
discovered  that  in  by  far  the  greatest  number  of  fatal  cases  the  intestines 
showed  no  evidences  of  disease. 

To  this  general  statement  there  were,  nevertheless,  numerous  excep- 
tions. Sutton  (1806),  William  (1801),  Muir  (1811),  Bateman  (1819)  and 
others,  published  accounts  of  outbreaks  of  fever,  prevailing  principally 
in  the  autumn,  and  attended  by  diarrhoea,  in  which,  after  death,  the  in- 
testines were  found  to  be  "inflamed  and  gangrenous."  Edmonstone 
(1818)  recorded  an  extremely  interesting  history  of  an  outbreak  of  enteric 
fever  at  Newcastle  in  1817.     This  fever  presented  striking  contrasts  to 

'  These  inaugurale  sur  la  dothienenterie.     Paris,  1826. 

■  De  la  maladie  a  laquelle  M.  Bretonneau  a  donne  le  nom  de  dothienenterie  ou  de 
dothienenterite.     Archiv.  gen.  de  medecine,  Ser.  I. ,  Tome  X. ,  1826. 

Notice  sur  la  contagion  de  la  dothienenterie.     Archiv.  gen.  de  medecine,  Ser.  I., 
Tome  XXI.,  1829. 


112  THE  CONTINUED  FEVERS. 

the  epidemic  fever  then  prevalent  in  various  parts  of  the  kingdom,  and 
which  at  a  later  period  fell  upon  Newcastle  itself.  Many  of  the  first  cases 
occurred  among  the  better  classes,  and  among  servants  residing  in  the 
best-aired  parts  of  the  town.  Children  and  young  adults  in  the  vigor  of 
life  were  almost  exclusively  affected.  The  duration  of  the  attack  was 
from  fourteen  days  to  a  month.  The  disease  was  thought  not  to  be  con- 
tagious, and  several  members  of  a  family  were  seized  at  the  same  time. 
It  was  almost  unknown  in  the  portions  of  the  town  inhabited  by  the  poor, 
and  in  which  typhus,  upon  its  appearance,  chiefly  prevailed.  The  symp- 
toms included  vomiting,  purging,  bleeding  at  the  nose,  and  hemorrhages 
from  the  intestines.  Abercrombie  (1820),  Hewett  (1826),  and  Bright 
(1827)  recorded  cases  of  fever  in  which  the  lesions  of  enteric  fever  were 
found  after  death.  Alison  (1827)  stated  that  he  had  encountered  in  Edin- 
burgh the  intestinal  affections  described  by  French  authors;  but  he  main- 
tained that  they  were  not  found  after  death  from  the  ordinary  typhus. 
Tweedie  and  Southwood  Smith  (1830)  recorded  a  number  of  cases  that 
had  fallen  under  their  observations  in  the  London  Fever  Hospital,  in 
which,  after  death,  the  intestines  showed  ulceration  and  the  mesenteric 
glands  were  enlarged;  in  other  cases,  however,  these  parts  were  unaffected. 
These  lesions  thus  came  to  be  regarded  by  the  English  and  Scotch  pathol- 
ogists as  accidental  complications  of  fever,  and  one  of  the  earliest  results 
of  the  awakened  interest  in  the  study  of  the  morbid  anatomy  of  fever 
was  that  the  clinical  distinction  between  the  slow  nervous  fever  and  the 
malignant  fever  of  camps  and  jails  was  lost  sight  of,  both  in  France  where 
the  former  only  was  prevalent,  and  in  the  British  Isles,  where  the  two 
fevers  were  constantly  met  with  side  by  side. 

In  Germany,  however,  this  distinction  was  recognized.  Hildenbrand 
(1810)  pointed  out  the  difference  between  the  contagious  typhus  and  the 
non-contagious  nervous  fever.  From  this  period  the  typhxis  exanthema- 
ticiis  and  the  typhus  abdominalis  were  regarded  as  well-marked  varieties — 
a  view  which  is  not  yet  finally  abandoned  at  all  hands  in  Germany,  and 
which,  while  it  was  in  advance  of  the  doctrines  held  in  France  and  Eng- 
land at  the  period  of  which  we  are  writing,  nevertheless  has  since  had 
great  influence  in  retarding  the  spread  of  the  doctrine  that  they  are  es- 
sentially distinct,  separate,  and  independent  infectious  diseases. 

The  distinction  between  the  two  fevers,  based  upon  their  clinical  differ- 
ences, that  have  arisen  in  the  eighteenth  century,  had  been  lost  sight  of; 
that  resting  upon  the  differences  in  their  morbid  anatomy  failed  of  recog- 
nition because  of  the  confusion  of  the  symptoms.  It  remained  to  study  at 
the  same  time  the  symptoms  during  life  and  the  appearances  after  death, 
and  to  compare  them;  in  other  words,  to  apply  to  this  epidemic  fever 
of  Great  Britain,  typhus,  the  analytical  method  of  study  that  Louis  had 
applied  to  enteric,  the  endemic  fever  of  France.  This  done,  the  two  fevers 
were  no  lono-er  to  be  regarded  as  the  same  disease;  when  it  was  thoroughlv 


ENTERIC  OR  TYPHOID  FEVER,  113 

done,  they  were  not  even  to  be  looked  upon  as  varieties  of  the  same  dis- 
ease; they  were  to  unprejudiced  eyes  clearly  seen  to  be  separated  by  their 
causes,  their  symptoms,  their  course,  their  duration,  and  their  anatomical 
characters,  and  no  more  closely  related  to  each  other  than  that  they  are 
both  acute,  specific,  infectious  diseases. 

The  process  of  accumulating  the  necessary  facts  upon  which  to  base  a 
convincing  demonstration  of  the  non-identity  of  typhus  and  typhoid  fever 
was  a  slow  one.  From  the  appearance  of  the  first  edition  of  Louis'  great 
work  in  1829,  in  which  the^filivre  typho'ide  and  the  typhus  of  English  writers 
were  spoken  of  as  identical,  till  the  issue  of  the  second  edition  in  1841, 
the  question  of  the  identity  or  non-identity  of  these  two  fevers  attracted 
the  widespread  interest  of  medical  men  both  in  England  and  France. 

Prominent  among  the  names  of  those  engaged  in  the  discussion  which 
this  question  called  forth  are  those  of  Drs.  Peebles,  A.  P.  Stewart,  Perry, 
Barlow,  Lumbard,  Messieurs  de  Clautry,  Montault,  Rocheux,  and  Dr. 
Staberoh,  of  Berlin.' 

To  Drs.  Gerhard  and  Pennock,  of  Philadelphia,  belongs  the  honor  of 
having  first  in  America  clearly  set  forth  the  distinction,  between  the 
two  fevers,  that  was  gradually  taking  form  in  the  minds  of  the  British 
and  continental  physicians.  These  gentlemen  had  studied  enteric  fever 
both  in  France,  with  Louis,  and  afterward  in  America,  and  had  arrived 
at  the  conclusion  that  the  dotkienenterie  or  fi^vre  typho'ide,  of  the  French, 
and  the  prevalent  continued  fever  of  this  country  are  identical.  Upon  the 
appearance  of  typhus  in  Philadelphia,  in  the  spring  of  1836,  they  recog- 
nized it  as  a  different  disease  and  after  a  careful  study  of  the  epidemic, 
they  were  enabled  to  point  out  the  most  important  points  of  difference 
between  the  two  affections,  and  to  classify  the  epidemic  fever  among  the 
continued  fevers,  "  distinguished  by  the  terms  typhus,  typhus  gravior, 
petechial  fever,  etc." 

'•  By  diagnosis,"  Dr.  Gerhard  wrote,  "  we  mean  the  comparison  of  all 
the  symptoms  appreciable  by  us  in  disease.  This  comparison  requires  a 
careful  examination  of  the  symptoms  presented  during  life,  and  of  the 
phenomena  observed  after  death,  in  such  cases  as  terminate  unfavorably. 
AVe  do  not  base  our  classification  of  diseases  solely  upon  their  anatomical 
lesions,  although  those  lesions  are  oftentimes  more  constant  than  any 
other  single  symptom  whatever  ;  but  we  group  together  lesions  and  symp- 
toms whenever  they  occur  together  with  sufficient  frequency  to  admit  this 
process  of  generalization." 

Proceeding  to  compare  the  two  fevers  upon  this  plan,  they  showed  that 
tlie  lesions  of  Peyer's  patches  and  of  the  mesenteric  glands  invariably 
present  in  enteric,  were  never  found   in  typhus;   and  that  English  obser- 


^  For  a  detailed  account  of  the  conclusions  reached  by  these  observers,  see  Murchi- 
son.  It  is  to  his  work  on  the  continued  fevers  that  I  am  indebted  for  the  outline  and 
for  most  of  the  factri  of  this  historical  sketch. 

S 


114  THE  CONTINUED  FEVERS. 

vers  were  in  error  in  regarding  these  lesions  as  merely  complications  of 
typhus;  that  there  was  a  "  marked  difference  between  the  petechial  erup- 
tion of  typhus  and  the  rose-colored  spots  of  typhoid  fever  ;  "  that  the  train 
of  symptoms  associated  with  the  intestinal  lesions  was  very  different  from 
those  of  typhus,  and  that  "  the  distinctive  characters  of  the  two  diseases 
were  such  as  in  practice  would  not  allow  them  to  be  confounded."  They 
pointed  out  the  fact  that  typhus  is  very  contagious,  whilst  they  were  con- 
vinced that  "  dothinenteritis  is  certainly  not  contagious  under  ordinary 
circumstances,"  although  in  some  epidemics,  they  said,  "  we  have  strong 
reason  to  believe  that  it  becomes  so." 

Their  observations  and  conclusions  were  published  by  Dr.  Gerhard  in 
February  and  August,  1837.' 

Dr.  Shattuck,  of  Boston  (1839),  strongly  insisted,  after  watching  some 
cases  in  the  London  Fever  Hospital,  upon  the  existence  of  two  fevers  in 
England,  and  pointed  out,  in  a  paper  communicated  to  the  Medical  Soci- 
ety of  Observation  in  Paris,  the  distinctions  between  them  with  consider- 
able minuteness. 

During  1840  several  able  papers,  setting  forth  the  differences  between 
the  two  fevers,  made  their  appearance;  and  in  1841,  in  the  second  edition 
of  his  work,  Louis  declared  that  "  the  typhus  fever  of  the  English  is  a 
very  different  disease  from  that  with  which  we  are  occupied." 

Other  French  and  English  physicians  adopted  similar  views  ;  but  the 
doctrine  of  non-identity  met  with  general  opposition,  and  the  opposite 
view  continued  to  be  taught  in  most  of  the  medical  schools. 

In  America,  Bartlett,  in  his  work  on  the  "  History,  Diagnosis,  and 
Treatment  of  the  Fevers  of  the  United  States,"  ^  treated  of  typhus  and 
typhoid  fevers  as  distinct  diseases. 

Sir  William  Jenner,  in  a  series  of  papers  upon  "  Typhus  Fever,  Ty- 
phoid Fever,  Relapsing  Fever,  and  Febricula,  the  diseases  commonly 
confounded  under  the  term  Continued  Fever"'  (1849-52),  contributed 
greatly  to  the  final  overthrow  of  the  doctrine  of  the  identity  of  the  two 
fevers  first  named.  He  not  only  confirmed  and  extended  the  distinctions 
between  the  symptoms  and  post-mortem  appearances,  pointed  out  by 
previous  observers,  and  in  particular  by  Gerhard  and  Pennock,  support- 
ing his  statements  by  the  histories  of  carefully  recorded  cases  and  elabo- 
rate analyses  of  the  symptoms  and  anatomical  lesions  of  many  cases  of 
both  fevers,  but  he  also  demonstrated  the  non-identity  of  the  causes 
of  the  two  fevers,  and  showed  by  an  analysis  of  all  the  cases  admitted  to 
the  London  Fever  Hospital  in  two  years,  that  they  did  not  prevail  to- 
gether and  that  the  one  did  not  give  rise  to  the  other  ;   and  he  called  at- 


'  W.  W.  Gerhard,  M.D.  :  On  the  Typhus  Fever  which  occurred  at  Philadelphia  in 
the  Spring  and  Summer  of  1837.  American  Journal  of  Medical  Sciences  February 
and  August,  1837. 

-  Philadelphia,  18-12.  -  Medical  Times.     November,  1849.  to  March,  1851. 


ENTERIC  OR  TYPHOID  FEVER.  115 

tention  to  the  fact  that  an  attack  of  one  of  them  mostly  confers  immunity 
from  subsequent  attacks  of  the  same,  but  not  of  the  other  fever. 

From  the  period  of  the  appearance  of  these  papers,  the  doctrine  of 
the  specific  distinctness  of  enteric  and  typhus  fevers  was  gradually  ac- 
cepted; it  is  now  generally  entertained  in  all  parts  of  the  world.  If  there 
be  those  who  are  exceptions  to  the  rule  that  competent  observers  regard 
these  two  diseases  as  essentially  distinct,  they  are  very  few,  and  their  pro- 
tests no  longer  retard  the  progress  of  knowledge. 

The  geographical  distribution  of  enteric  fever  is  wide.  It  has  been  ob- 
served in  all  countries  and  in  every  climate.  It  is  endemic  in  the  British' 
Isles,  all  parts  of  Europe,  and  in  North  America,  Hirsch' has  reached  the 
conclusion  that  its  general  prevalence  in  Europe  and  America  dates  no 
farther  back  than  the  second  and  third  decades  of  the  present  century — 
that  is,  from  the  period  at  which  typhus  (der  Petechialtyphus)  became  less 
common,  and  in  part  disappeared  altogether. 

Enteric  fever  is,  according  to  Murchison,  common  in  Scotland,  more 
common  in  Ireland,  and  most  common  in  England,  but  everywhere  preva- 
lent within  the  United  Kingdom.  Dr.  Cayley,  in  his  Croonian  Lectures,* 
declares  that  upwards  of  eighty  per  cent,  of  the  cases,  if  properly  nursed 
and  fed,  that  is,  if  treated  upon  the  expectant  plan,  will  recover.  Some 
idea  of  the  extent  of  the  prevalence  of  enteric  fever  in  England  may  be 
formed  from  his  statement  that  upwards  of  73,000  persons  have  died  of  it 
during  the  past  nine  years  in  that  country  alone. 

There  is,  in  medical  literature,  abundant  evidence  that  this  fever  is  also 
endemic  in  France,  Spain,  Italy,  Turkey,  Switzerland,  Germany,  Russia, 
Norway  and  Sweden,  and  in  Iceland. 

In  North  America  it  is  endemic  from  Hudson's  Bay  to  the  Gulf  of 
Mexico.  In  new  and  sparsely  settled  districts,  where  the  land  is  being 
gradually,  strip  by  strip,  so  to  speak,  brought  under  cultivation,  the  ma- 
larial fevers  prevail;  after  a  time,  as  populations  increase,  the  malarial 
diseases  and  typhoid  fever  occur  side  by  side,  the  one  often  modifying  the 
symptoms  of  the  other  and  complicating  its  course  ;  and  finally,  when  the 
land  has  been  generally  taken  up  and  drained  and  tilled  for  some  genera- 
tions, and  when  the  population  has  grown  dense  and  villages  and  cities 
abound,  the  malarial  diseases,  true  agues  and  remittents,  come  to  impress 
communities  but  faintly,  or  they  disappear  altogether;  but  enteric  fever 
grows  very  common,  and  asserts  itself  as  the  predominant  endemic  disease 
in  proportion  to  the  neglect  of  the  sanitary  measures  by  which  alone  it 
can  be  kept  in  check  in  populous  localities. 


'  Handbuch  der  historisch-geographischen  Pathologie.  By  Dr.  A.  Hirsch,  Erster 
Band.     Erlangen,  1860. 

■'  On  Some  Points  in  the  Pathology  and  Treatment  of  Typhus  Fever.  By  Wm.  Cay- 
ley, M.D..  F.R.C.P.     London,  1880. 


116 


THE    CONTINUED    FEVERS. 


It  is  far  from  uncommon  in  tropical  and  subtropical  countries.  Many 
observers  have  met  with  it  in  India.  It  has  been  reported  as  occurring 
in  Egypt,  Algeria,  the  west  coast  of  Africa;  in  the  West  Indies,  Mexico, 
and  upon  the  Pacific  slopes;  Central  America  has  not  escaped  it,  and  it  is 
said  to  be  extremely  common  in  Brazil  and  Peru.  Enteric  fever  has  also 
been  encountered  in  the  British  settlements  of  Australia,  New  Zealand, 
and  Van  Diemen's  Land. 

In  tropical  countries  it  has  doubtless  been  frequently  confounded  with 
reiiiittent  fever. 

Etiology, 
i.  predisposing  causes. 

donate,  not  of  itself,  but  indirectly  as  determining  the  mode  of  life 
in  communities,  has  a  manifest  influence  upon  the  extent  of  the  prevalence 
of  enteric  fever.  This,  like  many  other  widely  prevalent  infectious  dis- 
eases, is  met  with,  as  has  been  just  indicated,  in  all  parts  of  the  world, 
but  manifests,  at  the  same  time,  a  decided  preference  for  certain  broad 
areas  or  belts  of  the  earth's  surface.  It  is  especially  frequent  and  con- 
stantly present  everywhere  in  Europe,  Great  Britain,  and  in  the  United 
States,  and  Southern  Canada.  These  countries  lie  within  the  limits  of  the 
northern  temperate  zone,  in  which  enteric  fever  possesses  a  fixity  of  tenure. 

The  season  of  the  year  is  a  predisposing  cause  of  great  importance. 
Epidemics  of  enteric  fever  commonly  occur  during  the  last  half  of  the 
year,  and  the  number  of  cases  in  localities  where  it  is  endemic  is  usually 
greatest  from  August  to  November,  decreasing  in  December;  and  is  low- 
est from  February  to  May,  again  increasing  in  June. 

Hirsch  found  that  519  epidemics  of  typhoid  fever  were  distributed 
among  the  seasons  as  follows:  in  the  spring,  29;  in  the  summer,  132;  in 
the  autumn,  168;  and  in  the  winter,  140;  and  of  116  circumscribed  epi- 
demics occurring  in  France  between  1841  and  1846,  recorded  by  de  Clau- 
brey,  20  began  in  the  first  quarter  of  the  year,  21  in  the  second,  39  in  the 
third,  and  36  in  the  fourth. 

The  following  table  shows  the  relative  frequency  of  typhoid  fever  in 
the  different  seasons: 


Number. 


Locality. 


488  Cases.. . 

74  Cases.. . 

355  Deaths. 

14,547  Cases... 

645  Cases. . . 

3,826  Deaths. 

183  Cases.. . 

131  Cases.. . 

5,988  Cases... 


I  Lausanne. 

Geneva. 

Geneva  (Canton). 

Nassau  (Duchy). 

Lowell  (Mass.). 

Massachusetts. 

Strasbourg. 

King's  Collej^e  Hosp. 

London  Fever  Hosp. 


Observer,    j 

Delaharpe 

Lumbard. 

D'Esjiiue. 

Franque. 

Bartlett. 

Curtiss. 

Forgret. 

Todd. 

Murchison 


Date.        Spring.  'Summer' Autumn!  Winter. 


1851 

1834-37 

1838-45 

184(M7 

1846-48 

1841 

1860 

1848-70 


44 
7 

70 

3,597 

102 

429 

38 

31 

759 


122 

24 

75 

3,095 

163 

671 

49 

35 

1,490 


211 

2S 

115 

4,837 

350 

1,183 

60 

51 

3,461 


111 

15 

95 

4,028 

130 

544 

36 

34 

1,278 


ENTERIC  OR  TYPHOID  FEVER.  117 

This  fever  is  so  much  more  common  in  the  latter  part  of  the  year  that 
it  has  received  in  some  districts  of  the  United  States  the  popular  names 
of  "  Autumnal  "  or  "  Fall  Fever." 

The  development  and  spread  of  enteric  fever  is  favored  by  the  high 
temperature  of  summer,  and  checked  by  the  lovv  temperature  of  winter. 
The  maximum  of  temperature  and  the  period  of  greatest  prevalence  of 
the  fever  are  separated  by  an  interval  of  two  or  three  months,  the  former 
occurring  in  July,  the  latter  in  September  and  October;  and  the  minimum 
of  temperature,  occurring  in  January,  precedes  the  period  of  the  least  pre- 
valence of  tlie  fever,  in  February  or  April,  by  a  like  interval,  so  that  if  the 
curves  of  temperature  and  of  the  frequency  of  enteric  fever  be  projected 
diagrammatically,  as  has  been  done  by  Liebermeister,'  they  v?ill  be  seen  to 
nearly  correspond. 

The  interval  of  about  two  months  is  not  accounted  for  by  the  suppo- 
sition of  Murchison  that  the  cause  of  the  disease  is  called  into  action  by 
the  proti acted  heat  of  summer  and  autumn,  and  that  the  2^^otracted  cold. 
of  winter  and  spring  is  required  to  impair  its  activity  or  destroy  it;  but 
this  time  is  probably  consumed,  as  Liebermeister  suggests,  in  the  penetra- 
tion of  the  warmth  to  the  places  where  the  poison  is  elaborated,  its  de- 
velopment outside  the  body,  the  stage  of  incubation,  and  the  period  from 
the  beginning  of  the  attack  to  the  admission  of  the  patient  to  hospital  or 
his  death.  On  the  other  hand,  the  time  between  the  lowest  temperature 
and  the  least  prevalence  of  the  disease  is  to  be  accounted  for  by  the  stage 
of  incubation  and  the  length  of  the  patient's  illness  before  admission  to 
the  hospital,  or  death  as  the  case  may  be,  the  poison  having  already  been 
introduced  into  his  body,  and  by  the  infection  of  new  cases  from  sources 
of  contagion  within  dwellings,  where  it  remains  unaffected  by  the  outside 
temperature. 

Closely  connected  with  the  subject  of  the  temperature  as  influencing 
the  prevalence  of  enteric  fever  is  the  state  of  the  loeather  as  regards  dry- 
ness and  moisture.  Hot  and  dry  summers  favor  the  development  of  the 
disease;  cold  and  wet  summers  check  it.  This  statement  is  supported  by 
the  concurrent  testimony  of  observers  in  all  countries.  In  England  the 
summers  and  autumns  of  1865,  18GG,  18G8,  and  1870  were  remarkable  for 
their  great  heat  and  prolonged  drought,  and  for  an  unusual  and  early  in- 
crease of  enteric  fever.  On  the  other  hand,  there  have  been  few  years  in 
wliich  the  summer  and  autumn  have  been  more  cold  and  wet  than  in  1860, 
while  the  remarkable  diminution  of  the  prevalence  of  enteric  fever  over 
the  whole  country  in  that  year,  and  in  London  during  the  wet  autumn 
of  1872,  Avas  a  subject  of  general  observation.  The  admissions  into  the 
London  Fever  Hospital  for  1860  fell  to  one-half  of  the  average  of  the  pre- 
vious twelve  years,  and  this  diminution  was  due  to  the  absence  of  the 
ordinary  autumnal  increase  (Murchison). 

'  Ziemssen's  Cyclopsedia  of  Medicine,  vol.  i. 


118  THE  CONTINUED  FEVERS. 

An  analysis  of  the  outbreaks  of  enteric  fever  which  occurred  in  Stutt- 
gart from  1783  to  1837,  made  by  Cless,  shows  that  all  arose  at  the  end  of 
the  summer  or  in  the  autumn,  and  that  all  had  been  preceded  by  unusual- 
ly hot  seasons.  Virchow  also  found  that,  in  Berlin,  the  years  in  which  the 
rainfall  was  small  were  attended  with  severe  epidemic  and  typhoid  affec- 
tions, while  in  wet  years  the  mortality  from  enteric  fever  was  decreased. 

Dryness  of  the  atmosphere  alone  does  not,  however,  lead  to  an  in- 
crease of  enteric  fever.  In  cities  and  other  localities  supplied  with  a  sys- 
tem of  underground  drainage,  warm  damp  weather  often  leads  to  an  out- 
break of  the  disease,  while  heavy  rainfalls,  by  flushing  the  drains,  remove 
the  causes  to  which  its  origin  and  spread  are  chiefly  due.  On  the  other 
hand,  outbreaks  of  enteric  fever  may  be  traced  to  the  influence  of  abun- 
dant rains  in  washing  the  germs  of  the  fever  into  water  used  for  drinking 
purposes,  particularly  where  the  water-supply  is  derived  in  part  from  ma- 
nured fields. 

Pettenkofer  and  Buhl  have  shown  that  the  prevalence  of  enteric 
fever  in  Munich  is  dependent  upon  changes  in  the  height  of  the  deeper 
springs  of  water.  When  the  water  steadily  rises,  typhoid  decreases;  when 
the  water  sinks,  it  increases.  This  observation  corresponds  with  the  state- 
ment just  made,  that  enteric  fever  is  much  more  frequent  after  hot  and 
dry  summers  than  after  cold  and  wet  ones.  These  observers  explained 
the  \'^rying  prevalence  of  enteric  fever  in  connection  with  changes  in  the 
ground-water  by  the  assumption  that  the  causes  of  typhoid  fever  lie 
deep  in  the  earth.  "When  the  water-level  sinks,  the  la3-ers  of  earth,  con- 
taining moist  organic  substances  and  exposed  to  the  air,  undergo  changes 
which  lead  to  the  development  of  the  fever-poison.  When,  on  the  con- 
trary, the  water  rises,  these  layers  of  earth  are  again  covered  and  the  de- 
velopment of  the  germs  arrested.  The  explanation  advanced  b}'  Buchanan 
and  Liebermeister,  namely  that  the  lower  the  water  is,  the  greater  must 
be  the  proportion  of  solid  matters  suspended  in  it,  and  that  therefore  in 
localities  where  typhoid  fever  is  endemic  and  the  specific  cause  is  in  the 
earth,  or  soaks  from  privies  into  the  earth,  this  poison  must  be  relatively 
more  abundant  in  the  water  the  lower  it  is,  is  probably  correct. 

Age  is  of  great  importance  among  the  predisposing  causes  of  enteric 
fever.  It  is  pre-eminently  a  disease  of  adolescence  and  early  adult  life. 
Of  5,911  cases  admitted  to  the  London  Fever  Hospital  during  twenty- 
three  years  (1848-70),  nearly  one-half,  or  46.55  per  cent.,  were  between 
fifteen  and  twenty-five  years  of  age,  and  more  than  one-fourth,  or  28.58 
per  cent.,  were  under  fifteen.  Less  than  one-seventh,  13.3  per  cent.,  were 
above  thirty,  and  only  1  in  71  exceeded  fifty,  (Murchison).  The  mean 
age  of  1,772  cases  was  21.25,  that  of  the  males  being  inconsiderably  higher 
than  that  of  the  females.  It  may  be  stated  that  the  greatest  predisposi- 
tion is  between  the  ages  of  fifteen  and  thirty,  and  that  it  diminishes  pro- 
gressively both  above  and  below  these  limits.     Cases  in  the  first  year  of 


ENTERIC  OR  TYPHOID  FEVER.  119 

life  are  exceedingly  rare.  The  same  is  true  of  old  age,  although  well 
authenticated  cases  of  enteric  fever  in  persons  seventy,  eighty,  and  even 
ninety  years  of  age,  are  reported.  The  infrequency  of  the  attack  in  the 
latter  periods  of  life  is  doubtless  to  be  accounted  for,  in  part,  by  the  fact 
that  many  persons,  having  already  passed  through  the  disease,  are  insus- 
ceptible to  its  poison. 

ISex  exerts  little  influence  as  a  predisposing  cause.  The  statistics  of 
enteric  fever,  almost  exclusively  collected  from  the  reports  of  hospitals, 
show  a  marked  preponderance  in  the  number  of  males.  This  preponder- 
ance is  to  be  explained,  not  by  an  increased  liability  on  the  part  of  men, 
nor,  in  truth,  to  increased  exposure  to  the  causes  of  the  disease,  but  by 
the  fact  that  in  most  places  more  men  than  women  seek  treatment  in  hos- 
pitals. 

Of  138  cases  observed  by  Louis  in  Paris,  106  were  males.  This  excess, 
however,  is  accounted  for  by  the  circumstance  that  a  large  number  of  males 
were  strangers  in  Paris,  and  could  not  be  treated  at  their  lodgings. 

Occupation  exerts  no  influence  whatever  as  a  predisposing  cause  of 
enteric  fever. 

The  mode  of  life  of  the  individual  is  also  without  influence.  Enteric 
fever  is  as  common  in  the  houses  of  the  affluent  as  in  the  most  crowded 
and  destitute  localities.  In  fact,  the  presence  of  stationary  wash-stands 
in  bedrooms,  and  the  arrangement  of  bathrooms  and  water-closets  near 
sleeping-rooms,  expose  the  well-to-do  to  dangers  of  infection  that  the  less 
fortunate  escape.  Enteric  fever  attacks  by  preference  strong  and  healthy 
persons,  passing  by  those,  for  the  most  part,  who  are  the  subjects  of  pre- 
vious severe  or  wasting  disease. 

There  is  no  relationship  whatever  between  enteric  fever  and  variola, 
and  enteric  fever  is  not,  as  has  been  suggested,  at  all  more  prevalent  in 
communities  protected  by  general  vaccination  than  in  those  less  fortunate 
in  this  respect.  The  suggestion  of  Dr.  Harley  that  scarlatina  and  enteric 
fever  are  different  manifestations  of  the  same  poison,  or  that  enteric  fever  is 
an  abdominal  scarlatina,  is  untenable.  The  two  diseases  are  essentially  dif- 
ferent in  their  causes,  course,  symptoms,  duration,  and  lesions  after  death. 

Habitual  exposure  to  the  poison  of  enteric  fever  confers  an  immunity 
from  the  disease.  Instances  are  recorded  where  successive  visitors  at  the 
same  house,  at  intervals  of  months,  or  even  years,  have  been  seized  shortly 
after  their  arrival  with  enteric  fever,  or  intestinal  catarrh,  from  which  the 
ordinary  inhabitants  were  exempt.  Persons  changing  their  residence,  from 
one  part  of  a  city  to  another,  have  not  unfrequently  been  attacked  with 
enteric  fever,  and  persons  coming  from  the  country  into  cities  very  fre- 
quently become  the  subject  of  the  disease.  The  French  observers  strong- 
ly insist  upon  recent  residence  as  a  predisposing  cause.  Of  129  cases 
Louis  found  that  73  had  not  resided  in  Paris  more  than  ten  months,  and 
102  not  more  than  twenty  months. 


120  THE  CONTINUED  FEVERS. 

It  has  oeen  suggested  that  one  of  the  causes  of  the  frequency  of  ty- 
phoid fever  in  the  early  autumn  in  our  American  cities,  among  well-to-do 
j3eople,  is  to  be  found  in  the  circumstance  that,  during  an  absence  of  two 
months  or  more  in  the  mountains  or  by  the  sea,  they  have  to  some  extent 
lost  the  immunity  acquired  by  habitual  exposure  to  sewer-emanations,  and 
return  to  the  atmosphere  of  the  city  unprotected. 

Severe  mental  disturbance,  fear,  sorroio,  care,  and  great  fatigue,  doubt- 
less render  individuals  less  able  to  resist  morbid  influences,  and  therefore 
act  as  accidental  predisposing  causes;  but  that  they  can  give  rise  to 
enteric  fever,  as  was  held  by  the  older  authors,  is  a  view  wholly  at  vari- 
ance with  modern  theories  of  the  cause  of  the  disease. 

Pregnant  and  lying-in  women,  and  those  who  are  nursing  infants, 
enjoy  a  relative  immunity  from  enteric  fever. 

n.    THE   EXCITING   CAUSE. 

Up  to  the  present  time  the  exciting  cause  of  enteric  fever  has  eluded 
all  attempts  to  demonstrate  its  nature,  either  by  chemical  analysis  or 
microscopical  examination.'  It  is  known  to  us,  as  are  the  causes  of  most 
of  the  infectious  diseases,  only  by  its  effects. 

'  Prof.  C.  J.  Eberth,  of  Zurich,  has  recently  examined  the  lymphatic  glands,  spleen, 
the  affected  parts  of  the  intestine,  and  the  liver,  kidneys,  as  well  as  other  organs, 
with  a  view  to  discovering  the  character  of  the  lower  organisms  said  to  be  the  excit- 
ing cause  of  typhoid  fever.  Of  twenty-three  cases  examined,  micro-organisms  were 
found  in  twelve — twelve  times  in  the  lymphatic  glands  and  six  times  in  the  spleen. 
They  were  much  more  numerous  in  the  lymphatics.  Eberth  does  not  regard  these 
organisms  as  micrococci.  They  usually  assume  the  rod  shape,  and  are  about  the  size 
of  the  bacilli  found  in  decomposing  blood,  only  with  the  difference  that  they  usually 
take  a  narrow,  oval,  or  stumpy  spindle  shape  rather  than  a  cylindrical  outline.  They 
are  slightly  rounded  at  the  end,  not  cut  off  sharp.  Together  with  these  rods,  small 
egg-shaped  forms  are  met  with,  resembling  micrococci.  Undoubted  spherococci  were 
not  observed.  The  peculiar  delicate  outline  of  these  bodies  serves  to  distinguish  them 
from  the  bacilli  of  putrefaction.  They  contain  one  to  three  spore-like  bodies,  and  are 
not  so  easily  stained  in  methyl  violet  as  the  ordinary  micrococci  and  bacilli.  Eberth 
gives  several  interesting  facts  regarding  the  number  of  organisms  found  at  different 
stages  of  typhoid,  and  concludes  by  asserting  the  probability  that  they  stand  in  some 
relation  to  the  essence  of  the  disease. —  Virchow^s  Archiv,  Band  LXXXI.,  1880. 

Professor  Klebs,  of  Prague,  also  believes  that  he  has  discovered  the  micro-organ- 
ism which  con.stitutes  the  specific  agent  of  typhoid  fever,  and  develops  his  views  in 
a  paper  entitled  "Der  Ileotyphus  eine  Schistomycose,"  published  in  the  ArcMofilr 
Experimentnle  PatTiolo[iie,  T.  XII.,  1880.  Professor  Klebs  has  for  a  long  time,  assisted 
by  his  pupils,  been  making  researches  in  this  direction.  He  writes  that  he  has  been 
able  to  find,  at  the  necropsy  of  twenty-four  persons  carried  off  by  dothinenteritis, 
microbes  in  various  organs :  in  the  intestinal  mucous  membrane,  in  the  thickness  of 
the  cartilages  of  the  larynx,  in  thtf  pia  mater,  in  the  foci  of  lobular  pneumonia,  in  the 
mesenteric  ganglia,  in  the  parenchymata  of  the  liver,  and  generally  diffused  in  the 
organs  which  showed  the  most  decided  lesions.     These  micro-organisins  showed  them- 


ENTERIC  OR  TYPHOID  FEVER.  121 

The  view  that  it  is  an  organic  poison  is  tenable  only  when  the  term 
poison  is  understood  in  the  broadest  sense.  A  poison  produces  sickness 
and  destroys  life,  but  it  cannot  infect.  Much  less  is  it  capable  of  indefi- 
nitely reproducing  itself  either  within  or  outside  of  the  body,  or  of  a  pro- 
longed continuous  existence,  during  which  it  successively  affects  an  end- 
less series  of  individuals  exposed  to  its  influence  in  precisely  the  same 
manner  and  without  exhausting  its  noxious  power.  The  ingenious  sugges- 
tion that  it  may  be  some  derivative  of  albumen  capable  of  setting  up,  in 
other  albumen  and  albuminous  compounds,  chemical  changes  by  "  cataly- 
sis," and  of  thus  inducing  the  series  of  changes  in  the  body,  which,  taken 
together,  constitute  enteric  fever,  lies  wholly  within  the  domain  of  hy- 
pothesis. Without  entering  upon  a  detailed  discussion  of  its  improbabil- 
ity and  its  inadequacy  to  explain  the  well-proved  facts  of  the  patho- 
genesis of  the  disease,  it  is  only  needful  to  state  that  no  derivative  of 
albumen  possessing  such  "catalytic"  properties  is  known,  and  that 
organic  compounds  of  the  kind  indicated  are  unstable;  so  that  it  is  im- 
probable that  they  would  remain  undecomposed,  in  such  localities  as  are 
the  favorite  lurking-places  of  the  germs  of  enteric  fever,  for  any  length 
of  time,  much  less  during  the  lengthened  periods  that  such  places  retain 
their  power  of  distributing  the  infection. 

Without  doubt  the  fever-producing  principle  is  an  organized  germ,  a 
micro-organism,  a  protomycete,  a  contagiicm  vivuni. 

It  is  by  this  theory  alone  that  we  can  understand  the  known  facts 
bearing  upon  the  origin  and  transmission  of  the  disease. 

Although  the  nature  of  the  germ  which  produces  enteric  fever  is 
unknown,  many  of  its  properties  are  established, 

1.  It  is  invariably  derived  from  a  previous  case  of  enteric  fever. 

2.  When  introduced  into  the  human  body,  it  is,  under  favorable  cir- 
cumstances, capable  of  indefinitely  reproducing  itself. 

3.  It  is  eliminated  with  the  fecal  discharges. 

4.  It  is  not  capable  of  producing  enteric  fever  in  other  persons  at 
once,  but  must  undergo  certain  changes  outside  the  body  before  it  ac- 
quires this  power. 

5.  It  retains  its  activity,  when  it  finds  its  way  into  favorable  situa- 
tions, for  a  lengthened  period  after  it  has  passed  out  of  the  body,  the 


selves  in  the  form  of  rods,  about  eighty  micrometres  in  length  and  0.5  to  0.6  micro- 
metre in  thickness.  They  have  been  constantly  observed  in  the  bodies  of  dothinen- 
teric  patients  since  the  attention  of  Professor  Klebs  was  drawn  to  the  subject,  and 
they  are  always  absent  from  the  organs,  and  specially  the  intestines,  of  subjects  who 
have  died  from  any  other  disease  than  typhoid. — British  Med.  Journal,  Oct.  IG,  1880. 
Further  researches  are  necessary  to  establish  the  causal  relation  between  particular 
forms  of  protomycetes  and  enteric  fever,  but  it  may  be"confidently  predicted  that  ere 
long  the  specific  cause  of  this  and  many  of  the  other  infectious  diseases  will  be  demon- 
strable. 


122  THE  CONTINUED  FEVERS. 

requirements  to  this  end  being  decomposing  animal  matter,  especially 
fecal  discharges  and  moisture.  Hence,  cesspools,  sewers,  drains,  dung- 
heaps,  wet  manured  soils,  are  its  usual  habitat. 

G.  There  is  reason  to  believe  that  in  such  situations  it  is  capable  of 
reproducing  itself. 

7.  It  remains  suspended  in,  and  may  be  conveyed  by,  water  used  for 
drinking  purposes,  and  usually  finds  access  to  the  body  by  this  means. 

8.  Suspended  in  the  atmosphere,  it  also  reaches  the  blood  by  means 
of  the  inspired  air. 

These  statements  are  supported  by  the  following  facts  and  observa- 
tions : 

1.  From  the  assertion  that  the  specific  cause  of  enteric  fever  is  mvari- 
ably  derived  from  a  previous  case  of  the  disease,  many  observers,  even 
among  the  most  recent  authorities,  strongly  dissent.  Among  them  Dr. 
Murchison  is  most  prominent. 

It  had  long  been  held  that  air  and  drinking-water,  polluted  with  de- 
composing sewage  and  other  kinds  of  putrefying  organic  matter,  were 
capable  of  causing  fever;  but  it  was  Murchison  who  first,  in  1858,  pointed 
out  that  the  fever  thus  produced  was  different  from  that  arising  from 
other  causes.  He  showed  that  the  fever  thus  caused  is  always  enteric, 
and  never  typhus  or  relapsing  fever;  that  its  origin  in  substances  of  this 
kind  accounted  for  its  endemic  prevalence  and  the  occurrence  of  circum- 
scribed epidemics;  that  it  also  accounted  for  its  attacking  the  rich  as  well 
as  the  poor,  its  occurrence  in  isolated  country-houses  as  well  as  in  towns 
and  cities,  and  for  its  increased  frequency  in  autumn  and  warm  seasons. 
He  adduced  many  conclusive  facts  in  support  of  these  statements.  It  is 
now  universally  admitted  that  the  cause  of  enteric  fever  is  traceable  to 
air  or  drinking-water  defiled  with  decomposing  organic  matter,  and,  in 
])articular,  with  the  emanations  from  seM'age. 

The  name  "pythogenic,"  signifying,  as  it  does,  "produced  by  putre- 
faction," is  based  upon  this  generally  received  opinion.  It  was  first  sug- 
gested by  Dr.  Murchison. 

But  Dr.  Murchison  and  his  followers  go  much  farther  thaw  this. 
While  admitting  the  now  unassailable  doctrine  that  the  poison  of  enteric 
fever  finds  its  way  into  drains,  sewers,  and  the  like,  by  means  of  the 
dejections  of  persons  ill  of  the  disease,  and  that  a  single  case  may  in  this 
manner  give  rise  not  only  to  other  cases,  but  even  to  extensive  epidemics, 
they  also  insist  that  the  specific  cause  of  this  disease  may  be  generated 
de  novo  in  sewage,  without  the  presence  of  the  enteric  excreta. 

In  support  of  this  opinion  two  principal  arguments  are  adduced.  The 
first  rests  upon  the  well-established  fact  that  persons  may  be  exposed  to 
recent  typhoid  stools  in  their  most  concentrated  form,  and  fail  to  contract 
the  fever  unless  decomposing  sewage  be  present.  Thus,  in  hospitals  the 
disease  rarely  extends  to  the  medical  officers,  the  attendants  upon  the 


ENTERIC  OR  TYPHOID  FEVER.  123 

sick,  or  to  the  other  patients.  In  nine  years  there  were  treated  in  the 
London  Fever  Hospital  3,555  cases  of  enteric  fever,  in  the  same  wards 
with  5,14:4:  patients  not  suffering  from  any  specific  fever.  Not  a  single 
case  of  enteric  fever  arose  among  the  patients  suffering  from  other 
maladies  in  the  whole  course  of  this  time,  although  it  was  a  common 
practice  for  them  to  use  the  same  water-closets  and  night-stools,  and  the 
use  of  disinfectants  was  exceptional.  In  tlie  same  hospital,  during  a 
period  of  twenty-three  years  up  to  1870,  5,988  cases  of  enteric  fever  were 
treated,  and  seventeen  of  the  resident  medical  officers  contracted  the  dis- 
ease, but  of  this  number  only  five  were  in  communication  with  the  enteric 
fever  cases,  and  twelve  occurred  at  a  time  when  serious  defects  existed 
in  the  drainage  of  the  house.  Since  1871,  1,447  cases  of  enteric  fever 
have  been  received  and  treated  in  the  same  wards  with  693  patients  suf- 
fering with  other  diseases,  and  in  this  period  only  three  nurses,  and  not  a 
single  patient,  have  contracted  the  disease.  On  several  occasions,  how- 
ever, cases  lying  in  other  wards  have  been  infected. 

Liebermeister  states  that  up  to  1865,  in  the  hospitals  he  had  visited, 
namely,  at  Greifswald,  Tubingen,  and  Berlin,  he  had  never  seen  a  single 
patient,  nurse  or  physician  attacked  by  enteric  fever,  although  such  cases 
were  placed  in  the  general  wards. 

Similar  observations  have  been  made  in  the  hospitals  at  Paris  and 
elsewhere  on  the  Continent. 

In  this  country  it  is  customary  to  treat  typhoid  cases  in  the  wards  of 
general  hospitals  side  by  side  with  other  patients.  I  have  never  known 
of  the  transmission  of  the  disease  to  other  occupants  of  the  wards,  nor  to 
the  attendants.  When  the  disease  has  appeared  as  an  epidemic  in  hospi- 
tals, it  has  seized  upon  persons  occupying  separated  wards  or  rooms,  and 
has  almost  invariably  been  traceable  to  defective  water-closets  or  leaking 
drain-pipes. 

There  are,  nevertheless,  observations  of  an  opposite  character.  Epi- 
demics have  on  many  occasions  appeared  in  hospitals,  and  particular 
hospitals  have  suffered  repeatedly  from  local  outbreaks;  but  these  ex- 
tensions of  the  disease  may  be  traced  to  local  causes.  Thus,  Liebermeis- 
ter states  that,  in  the  hospital  at  Basle,  during  his  service  of  six  years 
from  1865  to  1871,  such  hospital  infections  occurred  repeatedly.  During 
this  period  one  thousand  nine  hundred  cases  were  treated,  of  which,  in 
forty-five,  the  disease  originated  in  the  hospital.  In  addition  to  these  a 
number  of  cases  of  slight  febrile  affection,  probably  due  to  slight  infection, 
also  occurred,  and  cases  of  afebrile  intestinal  catarrh,  which  were  to  be 
imputed  to  the  typhoid  infection,  were  very  numerous.  Of  the  forty-five 
cases  of  the  developed  disease,  many  had  never  been  brought  in  contact 
with  the  fever  patients.  For  example,  a  patient,  who  had  gone  through 
an  attack  of  variola  in  the  isolated  wards  set  apart  for  that  disease,  was 
attacked   immediately  after  his  discharge,  with  fatal  typhoid  fever.     In 


124  THE  CONTINUED  FEVERS. 

the  wards  for  syphilis,  also  isolated,  and  in  the  surgical  wards,  some  cases 
arose.  Many  of  the  officers  of  the  house,  and  the  washer-women  in  par- 
ticular, who  never  entered  the  wards,  also  contracted  enteric  fever.  But 
there  were  facts  that  clearly  indicated  the  existence  of  foci  of  infection 
within  the  hospital.  Cases  occurred,  for  example,  with  notable  frequency 
.among  the  patients  and  nurses  in  two  rooms,  one  directly  above  the  other. 
A  wooden  pipe,  leading  from  the  main  sewer  to  the  roof,  passed  by  both 
.these  rooms.  The  sewer  was  faulty  in  construction  at  this  point,  so  that 
jnatters  accumulated  there.  It  was,  in  fact,  liable  to  become  choked. 
Attention  to  this  defect  and  its  correction  in  part  was  followed  by  satis- 
factory improvement.  It  would  appear  that  the  hospital  at  Basle,  where 
■enteric  fever  is  very  prevalent,  is  saturated  with  the  poison  of  this  disease, 
and  that  its  drainage  is  far  fi'om  efficient.  Not  only  have  numerous  cases 
•of  infection  occurred  since  the  observations  of  Liebermeister,  but  it  is 
stated  that  almost  all  the  new  attendants  have  suffered  from  abdominal 
■catarrh  without  fever. 

Observations  of  this  kind,  which  appear  to  show  that  enteric  fever  is 
not  transmitted  from  the  patient  to  those  about  him,  and  that  it  occurs 
promptly  in  those  who  are  subjected  to  the  emanations  from  choked  drains 
and  otherwise  defective  sewerage  at  a  distance,  lose  their  value  in  view  of 
the  fact,  now  generally  admitted,  that  the  specific  germs  cannot  produce 
the  disease  in  their  fresh  state,  in  the  recently  voided  dejections  of  the 
typhoid  patients.  In  truth,  these  very  observations  are  evidence  in  support 
of  this  view.  If  the  water-closets  in  connection  with  the  wards  occupied 
by  fever  patients  are  in  order  and  the  drains  free,  no  infection  takes  place; 
the  excreta  are  swept  away  before  there  is  time  for  them  to  develop  their 
poisonous  properties.  But,  if  the  closets  are  in  bad  order  and  the  dejec- 
tions remain  and  undergo  decomposition,  other  cases  arise  among  those 
who  use  them;  or,  if  the  drains  are  choked,  infection  arises — not  in  the 
neighborhood  of  the  patients,  but  at  distant  parts  of  the  hospital,  at  the 
point  of  obstruction,  that  is,  where  the  emanations  from  the  arrested,  or 
leaking  and  decomposing  excreta,  escape  into  the  atmosphere. 

The  well-known  fact  that  patients  taken  ill  at  a  distance  rarely  trans- 
mit the  disease  to  those  about  them  on  being  removed  to  their  own  homes, 
is  without  value  in  support  of  the  doctrine  of  the  independent  origin  of 
the  fever  from  decomposing  sewage  without  the  previous  introduction  of 
the  poison;  but  the  fact  that  such  cases  sometimes  do  give  rise  to  epi- 
demics, and  that  in  such  instances  there  is  alwaj^s  either  defective  drain- 
age, or  direct  or  indirect  contamination  of  drinking-water  by  soakage  or 
otherwise,  from  the  dejections  of  the  patient,  is  of  the  most  convincing 
force  in  support  of  the  opposite  view.  Persons  ma\'  be  exposed  to  the 
direct  emanations  from  decomposing  human  excreta,  and  drink  water  rich 
in  the  leakage  from  neglected  privy-wells  with  impunity,  as  regards  the 
danger  of  enteric  fever,  for  an  indefinite  period;   but  the  day  a  case  of  the 


ENTERIC    OR   TYPHOID    FEVER.  125' 

disease  appears  upon  the  scene,  the  danger  becomes  direct  and  enormous, 
and,  unless  it  is  at  once  appreciated  and  provided  against,  other  cases  arise. 
That  which  was  foul  and  indecent,  injurious  yet  incapable  of  occasioning 
a  specific  disease,  becomes  a  nidus  for  the  growth  of  a  poison  and  a  focus 
of  infection. 

The  following  case,  which  very  fully  illustrates  this  statement,  came 
under  the  observation  of  Dr.  Flint: ' 

"  In  1848,  in  a  little  settlement  called  North  Boston,  situated  eighteen  miles  from 
the  city  of  Buffalo,  consisting  of  nine  families,  all  being  within  an  area  of  a  hundred 
rods  in  diameter ;  but  the  few  houses  in  which  the  disease  occurred  were  closely 
grouped  together  around  a  tavern,  the  house  farthest  removed  from  the  tavern  being 
only  ten  rods  distant.  A  stranger  from  New  England,  travelling  in  a  stage-coach  which 
passed  through  this  settlement,  had  been  ill  for  several  days,  and,  on  arriving  at  this 
stopping-place,  was  unable  to  proceed  farther.  He  remained  at  the  tavern,  and,  after 
a  few  days,  died.  He  was  seen  by  several  physicians  of  the  vicinity,  and  there  can  be 
no  doubt  that  his  disease  was  the  same  as  that  with  which  others  were  subsequently 
aflEected.  Up  to  this  time  typhoid  fever  had  never  been  known  in  that  neighborhood. 
The  sick  stranger  was  seen  by  the  members  of  all  the  families  in  immediate  proximity 
to  the  tavern,  with  a  single  exception.  One  family  named  Steams,  having  quarrelled 
with  the  tavern-keeper,  had  no  intercourse  with  the  family  of  the  latter,  and  very  lit- 
tle with  the  other  families,  all  of  whom  were  tenants  of  the  tavern-keeper.  No  mem- 
ber of  the  family  of  Steams  saw  either  the  sick  stranger  or  any  of  those  who  were 
taken  ill  after  the  stranger's  death.  Members  of  the  family  of  the  tavern-keeper  were 
the  first  to  become  affected,  the  first  case  occurring  twenty -three  days  after  the  arrival 
of  the  stranger.  Other  cases  speedily  occurred  in  the  surrounding  families.  In  a 
month  more  than  one-half  the  population,  numbering  forty-three,  had  been  affected, 
and  ten  had  died.  Of  the  families  immediately  surrounding  the  tavern,  that  of  Stearns 
alone  escaped  ;  no  case  occurred  in  this  family. 

"  The  occurrence  of  the  disease  produced  great  excitement  in  the  neighborhood  ; 
poisoning  was  suspected,  and  Stearns  was  charged  with  having  poisoned  a  well  used 
in  common  by  all  the  families  except  his  own.  A  fact  which  encouraged  this  suspicion 
was,  the  common  well,  being  owned  by  the  tavern-keeper,  he  had  refused  permission 
to  use  it  to  Stearns,  who  had,  in  consequence,  been  obliged  to  dig  a  well  for  his  own 
use.  An  examination  of  the  water  from  the  common  well  showed  it  to  be  perfectly 
pure. 

'•  The  disease  was  undoubtedly  typhoid  fever.  Visiting  this  settlement  during  the 
prevalence  of  the  disease,  and  recording  the  symptoms  of  several  cases  then  in  prog- 
ress, the  clinical  history  furnished  abundant  evidence  of  the  nature  of  the  disease. 
Moreover,  I  made  an  examination  of  the  bodj^  of  one  of  those  who  had  died  with  the 
disease,  and  found  the  Peyerian  patches  ulcerated  and  the  mesenteric  glands  greatly 
enlarged. " 

Dr.  Flint  was  of  the  opinion  that  the  spread  of  the  fever  was  due  to- 
personal  intercourse  with  the  sick  stranger,  but  it  is  beyond  doubt  that 
the  water  from  the  well  served  as  the  means  of  transmission. 

The  second  argument  is  based  upon  the  not  uncommon  observation 


'  A  Treatise  on  the  Principles  and  Practice  of  Medicine.     By  Austin  Flint,  ^I.D; 
Second  edition.     Philadelphia,  1867. 


126  THE  CONTINUED  FEVERS. 

that  enteric  fever  has  broken  out  in  isolated  localities  in  which  it  had  not 
hitherto  been  known,  and  the  inhabitants  of  which,  as  far  as  could  be  dis- 
covered, had  had  no  communication  with  any  place  in  which  the  disease 
existed. 

The  following  instances  are  taken  from  a  large  number  of  observations 
of  like  character  collected  by  Dr.  Murchison. 

*'  In  August,  1829,  twenty  out  of  twenty-two  boys,  at  a  school  at  Clapbam,  within 
three  hours  were  seized  with  fever,  vomiting,  purging,  and  excessive  prostration. 
One  other  boy,  aged  three,  had  been  attacked  with  similar  symptoms  two  days  before, 
and  had  died  comatose  in  twenty-three  hours ;  another  boy,  aged  five,  died  in  twenty- 
five  hours ;  all  the  rest  recovered.  Suspicions  were  entertained  that  they  had  been 
poisoned,  and  a  rigorous  investigation  ensued.  The  only  cause  which  could  be  dis- 
covered was  that  a  drain  at  the  back  of  the  house,  which  had  been  choked  up  for 
many  years,  had  been  opened  two  days  before  the  first  case  of  illness,  cleaned  out,  and 
its  contents  spread  over  a  garden  adjoining  the  boys'  play-ground.  A  most  offensive 
effluvium  escaped  from  the  drain,  and  the  boys  had  watched  the  workmen  cleaning  it 
out.  This  was  considered  to  be  the  cause  of  the  disease  by  Drs.  Latham  and  Cham- 
bers, and  by  others  who  investigated  the  matter,  and  also  by  Sir  Thomas  Watson. 
The  morbid  appearances  in  the  two  fatal  cases  were  described  as  '  like  those  of  the 
common  fevers  of  this  country.'  Peyer's  patches  and  the  solitary  glands  of  the  small 
and  large  intestines  were  enlarged  like  '  condylomatous  elevations,'  and,  in  one  case, 
the  mucous  membrane  over  them  was  slightly  ulcerated.  The  mesenteric  glands  were 
enlarged  and  congested." 

In   June,  1861,  a  case  similar  to   those  at   Clapham   came  under  Dr. 

Murchison's  observation. 

"A  girl,  aged  nine,  was  seized  with  febrile  symptoms,  vomiting,  purging,  and  in- 
tense headache,  followed  by  acute  delirium,  and  died  forty-seven  hours  from  the  com- 
mencement of  her  illness.  After  death  the  characteristic  lesions  of  enteric  fever,  in 
an  early  stage,  were  found  in  the  bowels.  Accompanied  by  Dr.  Stewart,  I  visited  the 
rooms,  over  a  stable,  occupied  by  this  girl's  family.  The  privy  was  in  the  stable,  and 
drained  into  a  cesspool  near  the  door,  which  had  become  choked  up.  Over  the  cess- 
pool was  an  open  grating,  by  which  the  stable  drained  into  it,  and  frorn  which  the 
most  offensive  smells  had  issued  since  the  beginning  of  the  warm  weather — so  offen- 
sive that  the  horses  had  sometimes  to  be  removed.  The  girl  had  been  playing  close 
to  this  grating  at  the  time  of  her  seizure.  The  cesspool  did  not  communicate  with  the 
public  drain,  and  no  other  cases  of  fever  had  occurred  in  the  mews." 

*'  About  Easter,  1848,  a  formidable  outbreak  of  fever  occurred  in  the  Westminster 
School  and  the  Abbey  Cloisters,  and  for  some  days  there  was  a  panic  in  the  neighbor- 
hood respecting  the  '  Westminster  Fever. '  No  case  of  fever  had  occurred  in  the  Abbey 
Cloisters  for  three  years,  and  there  was  no  evidence  of  its  having  been  imported. 
Within  little  more  than  eleven  days  it  affected  thirty-six  persons,  all  of  the  better 
class,  and  in  three  instances  it  proved  fatal.  Shortly  before  its  first  appearance 
'there  occurred  two  or  three  days  of  peculiarly  hot  weather,' and  a  disagreeable 
stench,  so  powerful  as  to  induce  nausea,  was  complained  of  in  the  houses  in  question. 
It  was  found  that  the  disease  followed  very  exactly  in  its  course  the  line  of  a  foul  and 
neglected  private  sewer  or  immense  cesspool,  in  which  fecal  matter  had  been  accumu- 
lating for  years  without  any  exit,  into  which  tiio  contents  of  several  smaller  cesspools 


ENTERIC  OE  TYPHOID  FEVER.  127 

had  been  pumped  immediately  before  the  outbreak  of  fever.  This  elongated  cesspool 
communicated  by  direct  openings  with  the  drains  of  all  the  houses  in  which  it  occurred ; 
the  only  exception  was  that  of  several  boys  who  lived  in  a  house  at  a  little  distance, 
but  who  were  in  the  habit  of  playing  every  day  in  a  yard  in  which  there  were  gully- 
holes  opening  into  the  foul  drain." 

These  observations  are  open  to  the  serious  objection  that  in  none  of 
them  has  the  possibility  of  the  presence  of  germs  derived  from  previous 
cases  of  enteric  fever  been  excluded. 

The  account  of  the  outbreak  at  the  school  at  Clapham  is  not  sufficient- 
ly explicit  as  to  the  condition  of  the  drain  at  the  back  of  the  house, 
which  had  been  choked  up  for  many  years.  It  is  not  stated  whether  or 
not  it  connected  with  drains  with  the  neighboring  houses,  nor  whether 
there  had  been,  some  time  before,  cases  of  fever  in  the  house  or  neighbor- 
hood, nor  how  many  years  the  drain  had  been  choked  up.  If  this  case 
has  value  at  all  as  illustrating  the  subject  of  the  etiology  of  enteric  fever, 
it  seems  to  me  that  it  is  in  this,  that  it  shows  that  the  germs  of  the  dis- 
ease may  retain  their  vitality,  under  favorable  circumstances,  for  a  long 
period — )iicmy  years,  and  that,  when  so  long  imprisoned,  it  becomes  highly 
infectious  and  capable  of  producing  the  most  profound  disturbances  of 
the  functions  of  the  body  with  great  rapidity. 

In  the  second  example,  the  possibility  of  the  child's  infection  from 
an  entirely  different  source,  distant  from  her  home,  while  visiting  or  at 
school,  must  be  excluded  in  order  that  the  observation  may  have  weiglit 
in  the  argument. 

In  the  third  example  it  is  distinctly  stated  that  there  had  been  no 
case  of  fever  for  three  years,  and  that  there  was  no  evidence  of  its  having 
been  imported.  There  was,  however,  "  a  foul  and  neglected  private 
sewer  or  immense  cesspool,  in  which  fecal  matter  had  been  accumulating 
for  years  without  any  exit,  into  which  the  contents  of  several  smaller 
cesspools  had  been  pumped  immediately  before  the  outbreak  of  the 
fever."  It  is  to  be  remarked  that  fever  probably  had  occurred  in  the 
neighborhood  three  years  before,  as  the  expression  used  in  the  account 
indicates.  Now,  there  is  reason  to  believe  that  the  poison  retains  its 
activity  outside  the  body  for  a  long  time  under  favorable  circumstances, 
and  farther  on  examples  will  be  given  to  prove  that  it  does  actually  re- 
tain it  for  many  months.  Is  there  a  limit  to  the  time  ?  Where  then  is 
it  ?  If  the  contagion  remains  active  many  months,  why  not  three  years  ? 
In  this  "  immense  cesspool "  the  conditions  for  its  survival,  perhaps  also 
for  its  multiplication,  were  complete.  Moreover,  there  was  no  exit.  Im- 
mediately before  the  outbreak  of  fever  the  contents  of  this  pool  had  been 
agitated  by  the  pumping  into  it  of  several  smaller  depots  of  ordure  ! 
Who  can  be  sure  that  a  person  suffering  from  typhoid  fever,  in  a  mild  or 
even  grave  form,  had  not  used  some  one  of  these  numerous  wells  during 
the  period  preceding  the  occurrence  of  this  epidemic  ? 


128  THE    CONTINUED    FEVERS. 

These  observations  are  certainly  inconclusive,  and  they  are  neitlier 
better  nor  worse  than  tlie  others  of  a  long  list  adduced  in  defence  of  a 
view  that,  in  spite  of  the  ablest  advocacy,  is  gradually  giving  way  before 
the  overwhelming  force  of  accumulating  facts  that  need  no  logic  to  ren- 
der them  convincing. 

In  addition  to  the  example  observed  by  Dr,  Flint  at  North  Boston, 
and  given  above,  the  following  facts  are  cited  by  Dr.  Cayley  to  show  that 
the  contamination  of  drinking-water  by  fecal  matter  may  exist  for  an  in- 
definite period  without  giving  rise  to  enteric  fever,  but  that  upon  the  ar- 
rival of  an  infected  person,  the  disease  speedily  makes  its  appearance  as 
a  local  epidemic. 

One  is  tho.  well-known  outbreak  at  Over  Darwen. 

"  The  water-supply  pipes  of  the  town  were  leaky,  and  the  soil  through  which  thej 
passed  was  soaked  at  one  spot  by  the  sewage  from  a  particular  house.  No  harm  re- 
sulted till  a  young  lady  sufiEering  from  typhoid  fever  was  brought  to  this  house  from  a 
distant  place  ;  within  three  weeks  of  her  arrival  the  disease  broke  out,  and  one  thou- 
sand five  hundred  persons  were  attacked." 

A  second  took  place  at  Calne. 

"  A  laundress  occupied  the  middle  one  of  a  row  of  three  houses  supplied  by  one- 
well,  into  which  the  slop  of  the  laundress's  house  leaked.  She,  on  one  occasion  re- 
ceived the  linen  soiled  by  the  discharges  of  a  case  of  typhoid  fever,  and  after  fourteen 
days  cases  occurred  in  all  three  houses." 

' '  At  Nunney  a  number  of  houses  received  their  water-supply  from  a  foul  brook 
contaminated  by  the  leakage  of  the  cesspool  of  one  of  the  houses,  but  no  fever  showed 
itself  till  a  man  ill  with  typhoid  came  from  a  distance  to  this  house.  In  about  four- 
teen days  an  outbreak  of  fever  took  place  in  all  the  houses." 

The  record  of  the  outbreak  at  Lausen,  in  the  Canton  Baselland,  in 
1872,  is  of  great  value  as  illustrating  this  and  other  facts  in  the  patho- 
genesis of  enteric  fever.  From  the  time  of  the  passage  of  the  allied 
armies  in  1814,  Lausen  had  suffered  from  no  epidemic  of  typhoid  fever. 
Isolated  cases  had  never  spread  the  infection.  During  the  seven  years 
preceding  1872,  not  a  single  case  of  typhoid  had  occurred. 

"  This  village  is  situated  in  the  Jura,  in  the  valley  of  the  Ergolz,  and  consists  of 
one  hundred  and  three  houses,  with  eight  hundred  and  nineteen  inhabitants ;  it  was 
remarkably  healthy,  and  resorted  to  on  that  account  as  a  place  of  summer  residence. 
With  the  exception  of  six  houses,  it  is  supplied  with  water  by  a  spring  with  two 
heads,  which  rises  above  the  village  at  the  southern  foot  of  a  mountain  called  the 
Stockhalder,  composed  of  oolite.  The  water  is  received  into  a  well-built  covered 
reservoir,  and  is  distributed  by  wooden  pipes  to  four  public  fountains,  whence  it  is 
drawn  by  the  inhabitants.  Six  houses  had  an  independent  supply — five  from  wells, 
one  from  the  mill-dam  of  a  paper  factory. 

"On  August  7,  1873,  ten  inhabitants  of  Lausen.  living  in  different  houses,  were 
seized  by  typhoid  fever,  and  during  the  next  nine  days  fifty-seven  other  cases  occurred, 
the  only  houses  escaping  being  those  six  which  were  not  supplied  by  the  public  foun- 


ENTERIC  OR  TYPHOID  FEVER.  129 

tains.  The  disease  continued  to  spread,  and  in  all  one  hundred  and  thirty  persons 
were  attacked,  and  several  children  who  had  been  sent  to  Lausen  for  the  benefit  of 
the  fresh  air  fell  ill  after  their  return  home. 

"  A  careful  investigation  was  made  into  the  cause  of  this  epidemic,  and  a  complete 
explanation  was  given. 

"  Separated  from  the  valley  of  the  Ergolz,  in  which  Lausen  lies,  by  the  Stockhal- 
der,  the  mountain  at  the  foot  of  which  the  spring  supplying  Lausen  rises,  is  a  side 
valley  called  the  Furlenthal,  traversed  by  a  stream,  the  Furlenbach,  which  joins  the 
Ergolz  just  below  Lauseu,  the  Stockhalder  occupying  the  fork  of  the  valleys.  The 
Furlenthal  contained  six  farm-houses,  which  were  supplied  with  drinking-water,  not 
from  the  Furlenbach,  but  by  a  spring  rising  on  the  opposite  side  of  the  valley  to  the 
Stockhalder. 

"Now,  there  was  reason  to  believe  that,  under  certain  circumstances,  water  from  the 
Furlenbach  found  its  way  under  the  Stockhalder  into  one  of  the  heads  of  the  fountain 
supplying  Lausen.  It  was  noticed  that  when  the  meadows  on  one  side  of  the  Furlen- 
thal were  irrigated,  which  was  done  periodically,  the  flow  of  water  in  the  Lausen  spring 
was  increased,  rendering  it  probable  that  the  irrigation  water  percolated  through  the 
superficial  strata,  and  found  its  way  under  the  Stockhalder  by  subterranean  channels 
in  the  limestone  rock.  Moreover,  some  years  before,  a  hole  on  one  occasion  formed 
close  to  the  Furlenbach  by  the  sinking-in  of  the  superficial  strata,  and  the  stream  be- 
came diverted  into  it  and  disappeared,  while  shortly  after  the  spring  at  Lausen  began 
to  flow  much  more  abundantly.  The  hole  was  filled  up,  and  the  Furlenbach  resumed 
its  usual  course. 

"  The  Furlenbach  was  unquestionably  contaminated  by  the  privies  of  the  adjacent 
farm-houses,  the  soil-pits  of  which  communicated  with  it.  Thus,  from  time  immemo- 
rial, whenever  the  meadows  of  the  Furlenthal  were  irrigated,  the  contaminated  water 
of  the  Furlenbach,  after  percolation  through  the  superficial  strata  and  a  long  under- 
ground course,  helped  to  feed  one  of  the  two  heads  of  the  fountain  supplying  Lausen. 
The  natural  filtration,  however,  which  it  underwent  rendered  it  perfectly  bright  and 
clear,  and  chemical  examination  showed  it  to  be  remarkably  free  from  organic  im- 
purities ;   and  Lausen  was  extremely  healthy  and  exempt  from  fever. 

"  On  June  10th  one  of  the  peasants  of  the  Furlenthal  fell  ill  with  typhoid  fever,  the 
source  of  which  was  not  clearly  made  out,  and  passed  through  a  severe  attack,  with 
relapses,  so  that  he  remained  ill  all  the  summer  ;  and  on  July  10th  a  girl  in  the  same 
house,  and  in  August  a  boy,  were  attacked.  Their  dejections  were  certainly,  in  part, 
thrown  into  the  Furlenbach,  and  moreover,  the  soil-pit  of  the  privy  communicated 
with  the  brook.  In  the  middle  of  July  the  meadows  of  the  Furlenthal  were  irrigated 
as  usual  for  the  second  hay  crop,  and  within  three  weeks  this  was  followed  by  the  out- 
break of  the  epidemic  at  Lausen. 

"  In  order  to  demon.strate  the  connection  between  the  water-supj^ly  of  Lausen  and  the 
Furlenbach,  the  following  experiments  were  performed  :  the  hole  mentioned  above,  as 
having  on  one  occasion  diverted  the  Furlenbach  into  the  presumed  subterranean  chan- 
nels under  the  Stockhalder,  was  cleared  out  and  eighteen  hundred- weight  of  salt  were 
dissolved  in  water  and  poured  in,  and  the  stream  again  diverted  into  it.  The  next 
day  salt  was  found  in  the  spring  at  Lausen.  Fifty-six  pounds  of  wheat  flour  were 
then  poured  into  the  hole,  and  the  Furlenbach  again  diverted  into  it;  but  the  spring 
L'lusen  continued  quite  clear,  and  no  reaction  of  starch  could  be  obtained,  showing 
that  the  water  must  have  found  its  way  under  the  Stockhalder  in  part  by  percolation 
through  the  porous  strata,  and  not  by  distinct  channels." 

It  is  a   matter  of  the  commonest  observation   that  the  decomposition 
of  organic  substances,  and  the  drinking  of  water  containing  the  products 
9 


130  THE    CONTITs^UED    FEVEES. 

of  such  decomposition,  are  not  of  themselves  sufficient  to  produce  enteric 
fever.  These  are  the  conditions  favorable  to  the  development  of  the  poi- 
son; but,  in  order  that  the  disease  may  be  produced,  something  more  is 
necessary,  and  that  is  the  specific  poison  itself. 

The  view  that  enteric  fever  never  originates  spontaneously,  but  tluit 
every  case  is  due  to  the  continuous  transmission  of  the  poison,  the  sewers 
or  drains  serving  as  the  ordinary  means  of  conduction,  or  as  "a  direct  con- 
tinuation of  the  diseased  intestines,"  was  first  taught  by  von  Gietl,  in 
Munich.  It  was  afterward  ably  advocated  in  England  by  Dr.  Budd,'  and 
is  to-day,  though  not  generally  accepted,  steadily  gaining  ground.  If  we 
assume  tliat  a  fever  so  specific  in  its  clinical  and  anatomical  characters 
must  be  due  to  a  specific  cause,  and  that  the  specific  cause  is  an  organism 
of  some  kind,  the  view  that  the  poison  does  not  arise  independently,  but 
in  every  instance  from  a  parent  stock,  becomes  a  logical  postulate  of  these 
assumptions;  otherwise,  we  are  forced  to  accept  the  theorj'  of  spontane- 
ous generation.  If  we  admit  that  the  decomposition  of  organic  and  ex- 
crementitious  substances  in  some  instances  can  produce  enteric  fever — a 
specific  disease,  but  in  by  far  the  greatest  number  of  instances,  even  when 
every  predisposing  influence  to  the  disease  exists,  fails  to  do  so — we  are 
yet  left  to  grope  in  the  dark  for  the  cause  of  the  different  behavior  of 
such  substances.  It  is  conceded  on  all  sides  that  when  outbreaks  of  the 
disease  follow  the  introduction  of  a  case  into  a  locality  previously  free 
from  it,  the  affection  spreads  not  by  direct  contagion,  but  by  the  well- 
recognized  methods  of  sewage  contamination  from  the  dejections  of  the 
patient.  Examples  of  this  abound  in  recent  medical  literature.  The  ac- 
cidental presence  of  the  specific  poison,  and  its  prolonged  latent  existence, 
are  capable  of  explaining  every  case  of  the  apparently  spontaneous  origin 
of  the  disease,  with  less  violence  to  our  sense  of  the  relation  of  cause  and 
effect  than  the  doctrine  of  independent  origin.  Moreover,  there  are 
two  general  truths  relative  to  the  etiology  of  the  infectious  diseases  that 
aid  us  in  reaching  a  reasonable  conclusion.  First,  a  mild  case  of  such 
diseases  may  produce  by  infection  the  gravest  forms  of  the  disease  in  other 
persons.  Thus,  a  walking  case  of  typhoid  fever,  not  recognized  as  such, 
or  a  case  of  mere  intestinal  catarrh,  due  to  the  cause  of  typhoid,  may  im- 
port the  specific  germs  into  a  locality  previously  exempt,  and  in  this  man- 
ner give  rise  to  an  outbreak  apparently  spontaneous.  Secondly,  the 
contagium  is  capable  of  being  transported  in  the  bedding  or  clothing  of 
patients,  and  in  other  substances  which  may  serve  as  foniites.  There  is 
abundant  reason  to  believe  that  the  changes  in  the  stools  of  typhoid  fever, 


'  On  Intestinal  Fever :  its  Mode  of  Propagation.     By  W.  Budd,  M.D.      Lancet, 
Tol.  ii.     185G. 

Intestinal  Fever  Essentially  Contagious,  etc.     Ibid.     Vol.  ii.     1859, 
On  Intestinal  Fever.     Ibid.     Vol.  i.     18G0. 


ENTERIC  on  TYPHOID  FEVER.  131 

•which  give  rise  to  the  infection,  uia\^  take  place  not  only  in  drains,  sewers, 
and  other  similar  situations,  but  also  in  the  excrement  discharged  into 
the  clothes  or  the  beds  of  the  patients.  In  this  manner  the  germs  may 
gain  access  to  localities  in  which  no  case  of  the  disease  has  occurred 
within  the  memory  of  man;  and  if,  as  is  most  probable,  they  retain  their 
activity  for  a  long  time,  all  connection  with  any  previous  case  disappears 
from  the  memory  of  those  who  may  have  known  of  it,  and  when  new  cases 
arise  they  present  the  appearance  of  being  autocthonous.  It  is  possible 
to  conceive  of  other  methods  by  which  the  germs  may  be  imported  with- 
out the  importation  of  cases.  Moreover,  the  people  are  always,  the 
physicians  often,  untrained  to  the  kind  of  scrutiny  which  alone  will  re- 
veal the  channel  by  which  an  infectious  disease  reaches  a  new  quarter, 
unless  it  be  so  plain  that  the  wayfaring  man  need  not  err  concerning  it. 

The  following  observation  is  recorded  by  Dr.  Cayley.  It  illustrates 
the  statement  that  the  poison,  not  at  first  active,  becomes  so  within  a 
short  period  in  the  bed,  or  the  clothing,  or  about  the  person  of  the  pa- 
tient, just  as  in  the  drain  of  a  defective  water-closet  : 

"  A  boy  was  admitted  into  the  Middlesex  Hospital,  under  my  care,  on  March  27. 
1879,  suffering  from  a  very  severe  attack  of  typhoid.  For  several  days  he  lay  in  an 
unconscious  condition,  and  during  this  time  he  had  very  profuse  diarrhoea — twelve  to 
twenty  liquid  motions  daily — which  were,  for  the  most  part,  passed  in  the  bed  In 
the  next  bed  was  a  boy  aged  six,  who  had  been  admitted  on  April  10th,  with  acute  renal 
dropsy  and  bloody  urine.  He  was  kept  strictly  confined  to  bed,  and  never  got  up  to 
go  to  the  water-closet,  down  which  the  motions  of  the  typhoid  case  were  thrown.  On 
May  11th,  when  he  was  convalescing,  the  dropsy  having  disappeared  and  the  albumen 
much  diminished,  he  was  seized  by  typhoid  fever,  and  passed  through  a  moderately 
severe  attack,  with  a  well-marked  rash  and  characteristic  symptoms.  This  at  first 
eight  appeared  to  be  a  case  of  direct  contagion,  but  there  is  no  doubt  that  the  true 
explanation  is  this  :  the  bedding  of  the  first  patient  was  constantly  kept  saturated 
by  hia  liquid  motions,  and,  though  every  care  was  taken  to  change  the  linen  fre- 
quently, it  was  ob\aous,  from  a  distinctly  fecal  smell  which  was  always  present,  that 
the  bedding  or  mattress  remained  contaminated,  and  thus  time  was  given  for  the 
poison  to  develop  its  infectious  properties.  Another  patient  in  the  same  ward,  ad- 
mitted for  acute  rheumatism,  was  also  attacked  by  the  fever.  He  occupied  a  bed  on 
the  opposite  side,  and  never  came  near  the  first  case;  but,  being  convalescent,  he  used 
the  water-closet  down  which  the  motions  of  the  typhoid  case  were  thrown  ;  and  it  so 
happened  that  at  this  time  the  closet  was  out  of  order,  the  contents  were  retained, 
and  an  offensive  smeU  was  constantly  present.  Hence,  there  can  be  no  doubt  but  that 
he  was  infected  by  the  emanations  from  the  evacuations  of  the  first  ca-se." 

Murchison  relates  the  following  fact,  which  was  communicated  to  him 
"  on  excellent  authority."  It  proves  beyond  question  the  possibility  of 
the  transmission  of  the  infecting  principle  of  enteric  fever  to  a  consider- 
able distance,  without  the  direct  importation  of  a  case,  and  without  the 
person  who  serves  as  the  vehicle  of  importation  necessarily  becoming  the 
subject  of  the  disease: 


132  THE    CONTINUED    FEVERS. 

"  In  1859,  the  wife  of  a  butcher  residing  in  the  small  village  of  Warbetovve,  situate 
between  Launceston  and  Camelford,  on  the  Cornish  moors,  travelled  to  Cardiff,  in 
Wales,  to  see  her  sister,  who  was  ill  and  soon  after  died  of  '  typhoid  fever.'  She 
brought  back  her  sister's  bedding.  A  fortnight  after  her  return  to  Warbstowe,  another 
sister  was  employed  in  hanging  out  these  clothes,  and  soon  after  was  taken  ill  with 
'  typhoid  fever,'  which  spread  from  her  as  from  a  centre.  The  woman  who  had  been 
to  Cardiff  never  took  the  fever  herself ;  there  had  been  no  cases  in  Warbstowe  pre- 
vious to  her  return  ;  neither  were  there  any  cases  in  the  neighboring  villages,  either 
before  or  after. " 

The  frequency  with  which  washer-women  are  attacked  is  to  be  ex- 
plained by  the  fact  that  the  dejections  undergo  the  changes  necessar}''  to 
render  them  capable  of  producing-  the  disease  in  the  bed-linen  and  clothes 
of  the  patient. 

The  weight  of  evidence  is  decidedly  against  the  doctrine  of  the  inde- 
pendent origin  of  the  disease  from  decomposing  animal  matter  or  fecal 
discharges. 

There  remains,  however,  another  method  by  which  enteric  fever  has 
been  supposed  to  originate,  namely,  from  the  eating  of  diseased  meat. 
The  following  are  some  of  the  most  important  of  the  observations  upon 
which  this  supposition  rests  : 

"  On  July  10, 1839,  the  local  choral  society  held  a  festival  meeting  at  Andelfingen, 
in  the  Canton  of  Zurich,  after  which  513  persons  of  all  ages  sat  down  to  a  cold  colla- 
tion, consisting  chiefly  of  veal  and  ham.  It  was  noticed  at  the  time  that  neither  the 
veal  nor  the  ham  were  perfectly  good.  Some  portions  of  the  former  had  a  greenish 
color  and  a  disagreeable  smell ;  the  ham  also  is  said  not  to  have  tasted  well.  But 
most  of  the  guests  observed  nothing  amiss,  and  ate  heartily.  Of  the  513  persons  who 
partook  of  this  collation,  A21  were  subsequently  attacked  by  an  acute  febrile  disease, 
which  was  regarded  at  the  time  as  typhoid.  Thirty-four  inhabitants  of  Andelfingen 
were  also  attacked,  who  had  taken  no  part  in  the  choral  festival,  but  all  of  whom,  it 
was  ascertained,  had  been  supplied  by  the  same  butcher  who  had  furnished  the  veal 
and  ham  for  the  festival. 

'  •  The  day  after  the  festival  there  was  a  wedding  in  the  neighborhood  of  Andelfingen, 
at  which  15  persons  were  present,  only  one  of  whom  had  attended  the  choral  meeting. 
The  meat — veal  and  beef — for  the  wedding-breakfast  was  supplied  by  the  saxne 
butcher.    Of  these  15  persona  11  were  attacked. 

''  The  period  of  incubation  of  this  epidemic  was  very  variable.  A  few  were  seized 
with  nausea  and  vomiting  on  their  way  home,  but  this  was  ascribed  to  their  having 
drunk  too  much  wine.  Out  of  230  cases  in  which  the  incubation  period  was  ascer- 
tained, 43  were  taken  ill  during  the  first  five  days,  123  during  the  second  five  days, 
48  during  the  third  five  days,  and  10  during  the  fourth  five  days,  6  being  attacked  on 
the  nineteenth  day. 

''  The  symptoms  were  those  of  severe  gastro -intestinal  irritation,  with  high  fever, 
delirium,  stupor,  congestion  of  the  lungs,  and  great  prostration.  No  rose  rash  was 
observed,  but  in  some  cases  there  were  petechias.  The  duration  of  the  milder  cases 
was  about  eight  days ;  of  the  severer  ones,  three  to  four  weeks.  Convalescence  was 
slow,  and  often  the  hair  fell  out.  The  mortality  was  slight,  and  on  post-mortem  ex- 
amination, in  some  cases  there  were  infiltration  and  ulcerations  in  the  lower  part  of 


ENTERIC  on   TYPHOID  FEVER.  133 

the  ileum,  with  enlargement  of  the  spleen  ;  in  others  these  changes  were  not  ob- 
served. 

"There  can  be  no  doubt  as  to  the  meat  having  been  the  cause  of  the  epidemic,  as 
only  those  persons  who  had  partaken  of  it  were  attacked  ;  while  a  very  large  number 
of  persons  from  all  parts  of  the  canton  were  present  as  singers  or  spectators,  who  did 
■not  share  in  the  collation,  and  they  all  escaped.  But  great  doubts  have  been  expressed 
as  to  whether  it  really  was  typhoid  fever,  or  a  form  of  poisoning  resembling  sausage- 
ipoisoning." 

Liebermeister,  recognizing  the  importance  of  this  outbreak  in  refer- 
ence to  the  etiology  of  typhoid  fever,  made  a  careful  study  of  the  printed 
accounts  of  it,  and  came  to  the  conclusion  that  it  was  certainly  not  ty- 
phoid fever.  Of  more  than  five  hundred  persons  who  fell  ill,  only  nine  or 
ten  died.  He  was  at  first  led  to  the  conclusion  that  it  was  an  unusual 
form  of  trichinosis,  but  this  opinion  was  not  confirmed  by  the  microscop- 
ical examinations  that  had  been  made.  Liebermeister  considers  it  proba- 
hie  that  there  is  a  special  form  of  disease  produced  by  meat-poisoning. 

An  epidemic,  apparently  due  to  the  same  cause  as  that  which  occurred 
at  Andelfingen,  but  which  was  in  part  undoubtedly  typhoid  fever,  oc- 
<!urred  at  Kloten,  a  place  about  seven  miles  north  of  Zurich,  in  1878. 

"  On  Ascension  Day,  June  30th,  a  festival  was  held  of  the  united  choral  societies 
of  the  district,  together  with  choirs  from  Zurich  and  Winterthur.  The  festival  colla- 
tion was  furnished  by  the  landlord  of  one  of  the  inns,  who  himself  was  attacked  by 
the  epidemic.  The  food  supplied  consisted  of  ragout  of  veal,  roast  veal,  and  veal  sau- 
sages. 

*'  The  meat,  which  came  from  various  sources,  was  hung  up  in  the  meat- room  of  the 
inn,  and  the  day  before  the  festival  was  partly  roasted,  partly  minoed  up  for  sausages, 
and  the  fragments  used  for  the  ragout  were  cooked  on  the  following  day. 

"  Nothing  amiss  was  observed  with  the  ragout,  but  the  cold  roast  veal  was  in  part 
decomposed,  and  the  sausages  were  manifestly  bad.  In  consequence  of  this  they  were 
largely  distributed  among  the  spectators,  the  children,  and  persons  who  could  not 
afford  to  pay.  Out  of  090  persons  who  sat  down  to  the  collation,  290  were  attacked. 
In  all,  668  persons  were  infected  who  had  partaken  of  the  meat  provided  for  the  fes- 
tival, either  at  the  collation  or  at  the  inn,  or  who  had  been  supplied  with  it  at  home; 
besides  which,  49  secondary  cases  occurred — i.e.,  persons  who  subsequently  became 
affected  by  contagion,  without  having  eaten  of  the  meat.  All  other  sources  of  infec- 
tion could  be  almost  certainly  excluded,  and  Kloten  was  quite  free  from  typhoid  at 
the  time.  A  very  large  number  of  the  visitors  to  the  festival  ate  no  meat,  but  only 
drank  wine  ;  none  of  these  were  attacked.  And  it  was  clearly  shown  that  the  water 
was  not  the  cause  of  the  outbreak.  Many  persons  who  had  drunk  no  water  were  at- 
tacked, and  others  who  had  drunk  freely  escaped.  Several  persons  who  drank  wine  to 
excess,  and  consequently  vomited  in  the  evening,  afterward  escaped. 

"  The  incubation  period,  as  in  the  Andelfingen  epidemic,  was  for  the  most  part  very 
short.  Some  persons  were  taken  ill  on  the  second  day,  with  loss  of  appetite,  nausea, 
headache,  pain  and  swelling  of  the  belly,  and  slight  fever.  These  early  cases  were  the 
mildest,  and  many  patients  recovered  in  a  few  days.  The  greater  number  feU  ill  be- 
tween the  fifth  and  the  ninth  days.  The  symptoms  were  chills,  fever,  diarrhoea, 
great  prostration,  in  many  cases  early  and  violent  delirium.  Eplstaxis  frequently  oc- 
curred, and  also  profuse  intestinal  hemorrhage.     The  roseolous  rash  of  typhoid  waa 


184  THE    CONTINUED    FEVERS. 

present  in  almoat  all  the  cases,  and  in  many  was  remarkable  for  its  extensive  devel- 
opment, sometimes  leading  to  little  infiltrations  forming  distinct  elevations,  and  leav- 
ing behind  slight  pigmentations. 

"  Post-mortem  examination  showed  the  characteristic  appearances  of  typhoid  fever, 
infiltration,  and  sloughing  of  Peyer's  patches  and  the  solitary  glands,  with  character- 
istic ulcers  where  the  sloughs  were  detached ;  not  infrequently  also  infiltration  and 
sloughing  of  the  solitary  glands  of  the  large  intestine,  great  enlargement  of  the  mes- 
enteric glands  and  spleen. 

"  With  regard  to  the  meat  supplied,  the  following  facts  were  ascertained  :  forty- 
two  pounds  of  veal  were  furnished  by  a  butcher  at  Seebach.  taken  from  a  calf  which 
appears  to  have  been  at  the  point  of  death  from  some  disease,  when  it  received  the 
cou^)  de  [jrace  from  the  hands  of  the  butcher.  All  the  flesh  of  this  animal  was  sent  to 
supply  the  festival  at  Kloten  ;  but  the  liver  was  eaten  by  an  inhabitant  of  Seebach, 
and  he  was  attacked  by  typhoid  fever ;  and  the  brain  was  sent  to  the  parsonage  at 
Seebach,  and  all  the  household  became  affected  by  the  same  disease. 

"  It  was  also  ascertained  that  another  of  the  calves  which  supplied  the  veal  was  suf- 
fering from  umbilical  phlebitis  and  peritonitis,  and  was  at  the  point  of  death  when  it 
was  slaughtered.  The  veal  from  this  calf  had  been  kept  fourteen  days,  and  was  in  a 
decomposed  condition.  All  the  meat  was  placed  together  in  the  meat-receptacle  of 
the  inn,  which  was  m  a  horribly  filthy  state,  and  no  doubt  the  putrefying  flesh  of  this 
last  calf,  together  with  the  state  of  the  receptacle,  would  rapidly  excite  decomposition 
in  the  whole  supply." 

This  meat  was  possessed  of  two  injurious  qualities:  it  Avas  putrid, 
and  it  was  in  part  infected  with  the  specific  typhoid  poison  (Huguenin, 
Cayley).  In  accordance  with  these  two  causes  of  disease,  the  outbreak 
which  folloAved  the  eating  of  the  meat  was  composed  of  two  distinct 
groups  of  cases.  These  were,  respectively,  an  acute  gastro-intestinal  ca- 
tarrh arising  shortly  after  the  ingestion  of  the  food  and  due  to  its  putrid- 
ity, and  typhoid  fever,  showing  itself  after  a  more  or  less  extended  period 
of  incubation,  and  due  to  the  specific  cause  of  that  disease.  In  some  in- 
stances the  patients  suffered  from  both  of  these  diseases,  the  specific  fever 
arising  after  the  putrid  catarrh.     The  mortality  was  slight. 

In  reply  to  the  question  as  to  how  the  cause  of  typhoid  fever  found 
access  to  the  meat,  Dr.  Cayley  states  it  as  his  opinion  that  there  can  be 
but  little  doubt  that  it  was  derived  from  the  meat  supplied  by  the  butcher 
at  Seebach.  The  liver  and  brain  of  this  animal  were  eaten  at  Seebach  by 
persons  who  had  not  visited  Kloten,  and  who  were  attacked  by  typhoid 
fever  within  a  short  time.  This  calf  was  apparently  dying  of  disease 
when  slaughtered  by  the  butcher.  Huguenin  regarded  its  sickness  as  ty- 
phoid fever.  He  believes  that  this  fever  is  common  among  the  cattle  in 
Switzerland.  It  is  stated  that  in  the  house  of  one  of  tlie  persons  attacked 
in  the  Kloten  epidemic,  while  he  was  still  laid  up,  two  calves  fell  ill  and 
were  killed.  Their  intestines  showed  the  characteristic  lesions  of  typhoid 
fever,  and  it  was  thought  that  they  were  infected  by  the  dejections  of 
their  owner  in  the  early  days  of  his  sickness,  while  he  was  yet  going 
about. 


ENTERIC    OR   TYPilOJD    FEVER.  135 

Huguenin  states  that  the  meat  of  cattle  suffering  from  typhoid  fever 
is  often  eaten  without  injurious  effects,  some  change  of  decomposition 
being  necessary  to  call  the  poison  into  activity.  In  this  respect  the  de- 
velopment of  the  poison  is  the  same  in  infected  meat  and  in  the  alvine 
discharges  of  patients.  It  requires  time  and  decay.  It  may  be  permitted 
me  to  quote  another  instance  from  Dr.  Cayley,  who  has  been  at  great 
pains  to  collect  the  observations  bearing  upon  this  question  of  the  origin 
of  enteric  fever  from  diseased  meat.  This  example  took  place  recently  at 
Kronau. 

"  A  butcher  refused  to  buy  a  calf  because  it  was  ill ;  the  family  to  whom  it  be- 
longed, therefore,  ate  it  themselves,  and  six  members  were  attacked  with  typhoid 
fever." 

A  few  other  instances  of  outbreaks  due  to  like  causes  are  to  be  found 
in  recent  medical  literature. 

Important  as  these  observations  undoubtedly  are,  they  cannot  be 
looked  upon  as  evidence  that  enteric  fever  can  be  produced  by  the  eating 
of  putrid  or  decomposing  meat.  On  the  other  hand,  a  careful  scrutiny  of 
the  facts  lead  to  the  conclusion  that  whatever  may  be  the  disease  pro- 
duced under  such  circumstances,  and  however  closely  it  may  resemble  en- 
teric fever,  it  is  not  in  fact  that  disease  unless,  along  with  the  decomposed 
meat,  the  specific  cause  of  enteric  fever  has  been  introduced  into  the  body. 
Tliese  observations,  therefore,  so  far  from  being  looked  upon  as  favoring 
the  view  that  enteric  fever  can  arise  independently,  are,  when  carefully 
looked  into,  confirmatory  proof  that  it  arises  only  by  continuous  transmis- 
sion, and  that  the  poison  in  every  instance  is  derived  from  a  previous  case 
of  the  disease. 

In  confirmation  of  the  statement  of  Huguenin,  referred  to  above,  that 
typhoid  fever  occurs  among  the  cattle  in  Switzerland,  it  may  be  men- 
tioned that  several  observers  have  encountered  a  similar  disease  in  others 
of  the  lower  animals. 

Thus,  Jaccoud '  states  that  a  disease  altogether  analogous  has  been 
observed  among  several  species  of  animals,  especially  in  the  horse,  the 
ass,  the  rabbit,  the  hare,  much  less  commonly  the  dog  and  the  cat.  He  re- 
fers to  the  observations  of  Bruckmiiller,  Roll,  Serres,  and  Birch-Hirschfeld, 
in  connection  with  this  subject. 

The  last  of  these  gentlemen  studied  the  effects  of  the  introduction  of 
tlie  blood  and  diarrhoeal  products  into  the  bodies  of  rabbits  at  Dresden, 
in  1873.  The  animals  succumbed  to  the  injection  of  a  certain  quantity  of 
blood  subcutaneously,  but  the  characteristic  lesions  of  the  intestines  were 
not  found.  The  introduction  of  the  stools  by  the  mouth  was  also  without 
effect  in  producing  the  disease. 


'  Traite  de  pathologic  interne.     By  S.  Jaccoud.     Tome  II.     Fifth  edition.  Paris, 
1877. 


136  THE  CONTINUED  FEVEKS. 

A  different  result,  however,  followed  the  injection  of  the  intestinal 
products  into  the  cesophagus,  and  the  effects  were  proportionate  to  the 
quantity  of  the  matter  injected  and  to  the  gravity  of  the  disease  in  the 
patient  from  whom  it  was  derived.  The  animals  were  seized  with  fever, 
the  temperature  reaching  41°  C.  (105.8°),  great  emaciation,  diarrhoea;  after 
death,  swelling,  pigmentation,  and  in  ten  cases,  commencing  ulceration 
of  Peyer's  patches  was  found;  there  was  also  enlargement  of  the  mesen- 
teric gland  and  of  the  spleen.  In  several  cases  there  was  recent  pneu- 
monia, and  in  one  instance  an  intense  "  follicular  catarrh  "  of  the  large 
intestine.  Birch-Hirschfeld  does  not  regard  the  disease  thus  artificially 
produced  as  identical  with  enteric  fever,  but  its  resemblance  is  very  close. 

Many  experimental  efforts  to  produce  enteric  fever  in  the  lower  ani- 
mals, by  exposing  them  to  the  emanations  from  decomposing  animal 
substances,  the  effluvium  from  cesspools  and  the  like,  have  been  made 
without  result.  If  the  view  of  the  nature  of  the  cause  of  the  disease  advo- 
cated in  these  pages  be  correct,  the  failure  of  such  experiments  is  to  be 
looked  for,  in  all  cases  where  the  decomposing  material  is  not  derived 
from,  or  commingled  with,  the  dejections  of  previous  cases. 

Murchison  fed  a  pig  upon  barley-meal  mixed  with  the  fresh  stools  of 
enteric  fever  patients  for  six  weeks.  The  animal  appeared  to  suffer  '  no 
inconvenience,'  but  grew  very  fat,  and,  when  killed,  its  intestines  were 
found  to  be  perfectly  healthy.  The  same  observer  believes  that  there  is 
no  clear  proof  that  any  of  the  lower  animals  are  liable  to  enteric  fever. 
To  this  opinion  are  opposed  the  facts  of  the  epidemic  at  Kloten,  as  well 
as  the  statement  of  Huguenin,  and  the  strong  probability  which  the  re- 
sults of  Birch-Hirschfeld's  experiments  carry  with  them.  In  view  of  the 
probability  that  cattle,  and  particularly  milch-kine,  are  occasionally  subject 
to  enteric  fever,  the  question  as  to  whether  or  not  the  disease  is  com- 
municable by  means  of  the  milk  of  animals  suffering  from  it,  assumes 
great  importance.  It  is  a  question,  however,  that  can  be  settled  only  by 
future  observations. 

3.  JFhcn  the  germ  of  enteric  fever  is  introduced  into  the  body,  it  is 
cafpahle,  tmder  favorable  circumstances,  of  indefinitely  reprodticing  itself. 

In  this  respect  the  specific  cause  of  enteric  fever  in  no  way  differs 
from  that  of  the  other  acute  infectious  diseases.  It  is  a  result  of  this 
power  of  reproduction  in  the  cause,  that  a  single  case  may  become  the 
focus  of  a  local  or  general  epidemic. 

The  time  between  the  introduction  of  the  poison  into  the  body  and 
the  development  of  the  symptoms  of  the  disease — the  period  of  incuba- 
tion— is  occupied  by  this  process,  but  it  certainly  does  not  come  to  an 
end  with  the  outbreak  of  the  attack.  The  causes  of  true  relapses  are  in- 
volved in  great  obscurity,  but  it  is  probable  that  they  arise  in  consequence 
of  the  multiplication  of  some  colony  of  germs  within  the  body,  that  have 


ENTERIC  OR  TYPHOID  FEVER.  137 

not  passed  through  the  usual  phases  of  development  at  the  same  time 
with  the  others,  and  undergo  such  changes  at  a  later  period;  or  else,  that 
they  are  due  to  reinfection  from  the  patient's  own  decomposing  discharges 
retained  in  his  clothes,  bedding,  upon  his  person,  or  about  the  drains  con- 
nected with  his  room. 

The  length  of  the  period  of  incubation  is  variable.  The  difficulties  in 
fixing  it  arise  from  the  difficulty  in  determining,  in  a  disease  due  to  in- 
direct contagion,  the  exact  date  of  infection  on  the  one  hand,  and,  wlien 
the  onset  of  the  attack  is  insidious,  the  exact  date  of  the  beginning  of 
the  disease  on  the  other.  The  indefinite  prodromes  are  usually  included 
in  the  period  of  incubation,  and  the  attack  is  commonly  dated  from  the 
commencement  of  the  fever.  It  is  not,  however,  often  in  practice,  that 
the  date  of  the  first  rise  in  temperature  can  be  ascertained. 

The  beginning  of  the  disease  must,  therefore,  be  reckoned  from  a 
much  less  definite  circumstance,  namely,  the  day  when  the  patient  is 
obliged  to  desist  from  his  ordinary  occupation,  or  to  betake  himself  to 
bed.  In  cases  where  the  period  of  invasion  is  distinctly  marked  by  rigors, 
one  of  the  chief  difficulties  in  regard  to  the  determination  of  the  length  of 
the  period  of  incubation  does  not  arise. 

It  is  probable  that  in  children  the  prodromic  period  is  often  included 
in  the  fever,  for  the  reason  that  the  nervous  system  reacts  to  relatively 
slight  disturbing  influences  much  more  strongly  than  in  adults.  This  may 
explain  the  fact  that  many  of  the  instances  of  apparently  short  periods 
of  incubation  have  occurred  in  children.  This  supposition,  however,  cer- 
tainly does  not  account  for  the  remarkable  instance  of  the  school  at  Clap- 
ham,  in  1829.  Here,  twenty  out  of  twenty-two  boys  were  attacked, 
within  four  days  of  their  exposure  to  the  effluvia  from  materials  removed 
from  an  old  stopped  drain,  by  vomiting,  purging,  fever  and  extreme  pros- 
tration, and  two  died  within  twenty-four  hours.  The  symptoms  of  the 
stadium p7'odromoricm  doubtless  assumes  in  children  much  greater  severity 
than  at  later  periods  of  life,  but  the  occurrence  of  fever  and  the  rapidly 
fatal  result,  indicate  that,  in  these  cases,  the  actual  disease  began  with 
the  occurrence  of  the  symptoms  named,  and  it  appears  probable  that  the 
shortness  of  the  period  of  incubation  was  due  to  the  enormous  amount  of 
the  fever-producing  principle  and  its  concentration.  It  is  proper  to  state 
that  doubts  have  been  entertained  as  to  the  precise  nature  of  this  fever; 
but  Dr.  Murchison  and  others,  who  have  carefully  studied  its  history,  are 
of  the  opinion  that  it  was  typhoid,  and  cases  of  undoubted  typhoid  have 
been  repeatedly  observed  which  were  due  to  a  similar  cause  and  attended 
by  a  like  symptom-grouping. 

There  is  reason  to  believe  that  the  period  of  incubation  is  longer  when 
the  poison  finds  access  to  the  patient's  system  by  means  of  the  ingesta 
than  when  by  means  of  the  air;  but  the  facts  thus  far  advanced  in  sup- 
port of  this  opinion  are  too  few  to  warrant  a  positive  conclusion. 


138  THE  CONTINUED  FEVERS. 

Cases  are  not  uncommon  in  which  diarrhoea,  vomiting,  headache,  and 
the  like  occur  for  a  day  or  two  in  persons  who,  in  the  course  of  a  fort- 
night or  more,  develop  the  symptoms  of  enteric  fever.  These  symptoms 
subside,  but  the  patient  does  not  regain  his  feeling  of  health  during  the 
intervening  period.  It  is  probable  that  the  poison  in  such  instances  exer- 
cises a  primary  irritating  influence  upon  the  intestinal  mucous  membrane 
at  the  time  of  its  absorption,  and  thus  occasions  a  transient  gastro-intes- 
tinal  catarrh,  which  is  followed  at  the  termination  of  the  incubative 
period  l)y  the  attack. 

The  duration  of  this  period  is  commonly  about  fourteen  days,  but 
great  variations  are  met  with. 

Murchison  places  it  at  two  weeks,  having,  however,  met  with  only  two 
cases  in  his  own  experience  that  shed  any  light  upon  the  matter.  In  one 
of  these  it  was  not  longer  than  fourteen  days;  in  the  other  not  longer 
than  twenty-one.  Budd,  as  the  result  of  the  stud}'  of  a  large  number  of 
cases,  was  led  to  the  conclusion  that  it  varies  from  ten  to  fourteen  days. 
There  is  evidence  that  the  period  of  incubation  may  be  much  shorter. 
Greisinger '  relates  three  instances  in  which  the  attack  began  within 
twenty-four  hours  after  exposure  to  the  infection.  These  cases  are  so 
often  referred  to,  yet  appear  to  me  so  inconclusive,  that  I  cite  them  in 
order  to  show  how  little  value  they  possess,  rather  than  as  illustrations  of 
very  short  periods  of  incubation. 

' '  One  day,  while  sitting  by  the  bedside  of  a  patient  very  ill  of  enteric  fever,  whom 
he  had  examined  for  a  considerable  time,  he  suddenly  felt  unwell  and  thought  he  had 
caught  the  fever.     The  next  day  he  was  taken  ill. 

' '  One  of  the  patients  of  his  clinic  had  gone,  perfectly  well,  to  nurse  a  case  of  en- 
teric fever.     She  slept  the  first  night  in  the  sick-room,  and  the  next  day  was  taken  ill. 

' '  A  man  passed  a  quarter  of  an  hour  in  a  building  where  there  were  cases  of  the 
fever  (in  einem  Typhus-hause),  and  he  fell  ill  the  following  day." 

From  what  is  now  known  of  the  nature  of  the  cause  of  enteric  fever, 
it  is  in  the  highest  degree  improbable  that  the  fever  was  contracted  in 
any  of  these  cases,  at  the  time  Griesinger  supposed.  If  it  could  be  shown 
that  these  persons  had  not  been  exposed  to  the  contagion  before,  the 
cases  would  be  startling  examples  of  short  incubative  periods.  As  it  is, 
Greisinger  himself  had  undoubtedly  been  constantly  exposed  to  it,  and 
the  presumption  that  the  others  had  also  been  previously  exposed  amounts 
almost  to  a  certainty,  in  view  of  the  overwhelming  evidence  that  the 
period  of  incubation  is  always  longer  than  in  these  instances. 

The  following  examples  of  unusually  short  periods  are  related  by 
Professor  Quincke,  of  Bern: 

'  Virchow's  Handbuch  der  specielleu  Pathologie  und  Therapie.  Band  II. ,  AbtheiL 
II.     Erlangen,  1864. 


ENTERIC    OR   TYPHOID    FEVER.  loO" 

"  Three  boys  played  on  successive  days,  from  March  loth  to  16th,  with  some  straw 
from  .1  mattress  soiled  with  the  discharge  of  a  fatal  case  of  typhoid.  All  three  were 
infected ;  the  first  was  taken  ill  on  March  22d.  Here  the  maximum  limit  was  nine, 
the  minimum  three  days." 

"Another  case  was  that  of  a  woman,  who  came  from  a  distance  to  an  infected 
house,  where  she  stayed  two  or  three  days.  She  felt  ill  on  her  way  home,  and  after 
a  few  days  took  to  her  bed,  and  died  on  the  fourteenth  day.  Here  the  maximum 
limit  was  six  days." 

Here  the  probability  that  the  beginning  of  the  period  of  incubation 
was  determined  within  the  limits  indicated  is  very  great,  but  it  is  im- 
possible to  exclude  a  previous  infection. 

Instances  of  a  longer  duration  are  much  more  common.  An  incuba- 
tion of  twenty-one  days  is  far  from  rare.  Liebermeister  places  it  at  three 
weeks  as  an  average,  and  states  that  it  sometimes  reaches  four.  A  longer 
duration  than  this  is  mentioned,  but  such  protracted  periods  may  be 
ascribed  to  errors  of  observation. 

The  variations  are  doubtless  in  part  to  be  attributed  to  constitutional 
peculiarities  on  the  part  of  the  patient,  rather  than  to  differences  in  the 
poison  or  the  mode  of  its  introduction.  Thus,  several  persons  may  be  in- 
fected at  the  same  time  and  in  the  same  manner,  yet  fall  sick  at  variable 
intervals  of  time  afterward.  The  following  instance  of  the  infection  of  a 
number  of  persons  by  drinking-water  at  the  same  time  illustrates  the 
foregoing  statement.     It  is  related  by  Professor  Quincke  : 

"On  June  23,  1873,  the  Federal  Gymnastic  Festival  was  held  at  Miinsingen,  a 
village  situated  about  seven  miles  from  Bern,  and  there  was  a  large  gathering  of  visit- 
ors from  all  parts  of  Switzerland,  most  of  whom  left  Miinsingen  the  same  daj'.  It  so- 
happened  that  the  wife  and  son  of  the  landlord  of  one  of  the  inns,  which  was  close 
to  the  ground  where  the  gymnastic  meeting  was  held,  were  ill  with  typhoid  fever, 
and  only  ten  feet  from  the  leaky  soil-pit  of  the  privy  of  the  inn  was  a  well  from  which 
water  was  supplied  to  the  persons  taking  part  in  the  festival,  as  well  as  to  those  who 
took  refreshments  at  the  inn  itself.  An  epidemic  of  typhoid  fever  broke  out  among 
persons  who  had  attended  this  festival,  and  the  particulars  of  fourteen  cases,  occur- 
ring among  visitors  who  came  from  places  free  from  typhoid,  have  been  ascertained. 
In  one  case  the  attack  commenced  eight  days  after  the  festival,  in  three  cases  on  the 
twelfth  day,  in  one  case  on  the  thirteenth  day,  in  two  cases  on  the  fourteenth  day, 
in  two  cases  on  the  fifteenth  day,  in  two  cases  on  the  sixteenth  day.  in  two  cases  be- 
tween the  sixteenth  and  eighteenth  days,  and  in  one  case  some  time  between  the 
fourteenth  and  twenty-second  days,  when  the  patient  first  came  under  medical  obser- 
vation. " 

The  germ  may  find  access  to  the  body  without  thereafter  undergoing 
the  changes  and  indefinite  reproduction  necessary  to  give  rise  to  the 
fever.  In  order  to  this  certain  favoring  conditions  are  requisite.  What 
those  conditions  are  we  do  not  know,  but  we  know  that  they  are  pre- 
vented in  many  instances  by  acclimatization,  and  in  most  by  a  previous 
attack. 


140  TUE  CONTINUED  FEVERS. 

Thus  it  is  well  known  that  persons  are  apt  to  be  attacked  in  removing 
to  a  locality  where  the  disease  is  endemic,  as  from  one  quarter  of  a  city 
to  another,  or  from  tlie 'country  into  the  city.  Jaccoud  states  that,  even 
,to-day,  Paris  presents  in  this  respect  exceptional  danger — a  danger  that 
is  imminent  for  several  months,  or  even  a  year  and  more.  After  a  time, 
if  the  patient  escape  the  attack,  the  danger  diminishes,  and  those  who 
have  passed  their  lives  in  such  localities  often  escape. 

The  immunity  from  a  second  attack  rests  upon  the  statements  of 
patients  who,  in  almost  all  cases,  state  that  they  have  not  previously 
suffered  from  the  disease,  and  upon  several  remarkable  observations, 
when  the  disease  has  become  epidemic  a  second  time  in  the  same  house 
or  locality,  after  the  lapse  of  several  years,  and  has  attacked  those  who 
escaped  before,  and  spared  the  others  who  had  suffered  in  the  prior  out- 
break. 

No  suggestion  adequate  to  explain  the  immunity  conferred  by  a  pre- 
vious attack  of  enteric  fever,  or  the  immunity  from  a  second  attack  in 
other  infectious  diseases,  has  yet  been  brought  forward.  The  fact  that 
second  attacks  do  occasional!}'  occur,  adds  not  a  little  to  the  obscurity  of 
the  question.  Murchison  met  with  several  instances  of  well-marked  sec- 
ond attacks  occurring  after  puberty,  and  many  more  of  attacks  of  enteric 
fever  in  persons  who  had  passed  through  "  infantile  remittent  fever," 
Instances  are  also  recorded  by  Trousseau,  Bartlett,  Budd,  and  others. 

I  attended  a  gentleman  through  an  attack  of  enteric  fever,  with  well- 
developed  eruption,  in  1873,  who  died  of  the  same  disease,  in  the  sjoring 
of  1880,  on  the  twenty-first  day  of  his  sickness.  At  the  necropsy  there 
were  found  infiltration  of  Peyer's  patches  without  ulceration,  enlarge- 
ment of  the  mesenteric  glands  corresponding  to  the  affected  intestinal 
tract,  and  enlargement  and  softening  of  the  spleen. 

That  a  certain  individual  susceptibility  to  the  poison  is  requisite  in 
•order  that  it  may  produce  the  disease,  is  evident  from  the  fact  that  in 
house-epidemics  due  to  contaminated  drinking-water,  or  to  the  pollution 
of  the  atmosphere  from  defective  sewers  and  the  like,  the  whole  house- 
hold, although  exposed  to  the  same  influences,  rarely  sicken  at  once,  but 
commonly  two  or  three  only  suffer,  or,  if  others  contract  the  disease,  it 
is  at  varying  intervals;  while  a  considerable  proportion  usually  escape 
altogether. 

3.  It  is  eliminated  with  the  fecal  discharges. 

The  alvine  dejections  appear  to  constitute  the  sole  means  of  the  com- 
munication of  the  disease.  In  this  respect  enteric  fever  resembles  cholera 
and  dysentery.  Typhus  fever  and  the  exanthemata  appear  to  be  com- 
municable by  the  emanations  from  the  surface  of  the  body  and  by  the 
exhaled  air,  the  specific  virus  being  given  off  from  the  cutaneous  and 
respiratory  surfaces;  but  all  the  evidence  bearing  upon  this  point  goes  to 


ENTERIC  OR  TYPHOID  FEVER.  141 

show  that  enteric  fever  is  not  communicated  in  this  manner.  The  atten- 
dants upon  the  sick  do  not  contract  the  disease  unless  tliey  are  also  ex- 
posed to  the  decomposing  excrements  of  the  patients,  or  to  the  continuing* 
influences  to  which  the  patient's  sickness  is  due  ;  the  garments  worn  by 
the  patient,  and  his  bedding,  do  not  communicate  the  disease  to  others 
unless  they  are  defiled  by  his  dejections;  finally,  persons  may  be  in  close 
relation  to  the  patient  without  contracting  the  disease,  while  others  in 
the  same  house,  who  have  had  no  communication  whatever  with  him,, 
are  occasionally  attacked. 

Piedvache  mentions  a  remarkable  instance  of  enteric  fever,  in  a  boys' 
school  at  Dinan,  that  strikingly  illustrates  the  last  statement  : 

"The  boy  first  attacked  was  nursed  by  his  fellow-pupils,  more  than  twenty  of 
whom  passed  the  night  with  him  during  his  illness,  and  used  no  precaution  against 
the  contagion.  Not  one  of  the  boys  thus  exposed  took  the  fever ;  but  the  second  case 
occurred  nineteen  days  after  the  death  of  the  first,  in  a  boy  who  had  had  no  communica- 
tion with  the  first  patient,  who  had  never  entered  his  room,  and  who  slept  in  a  re- 
mote part  of  the  building." 

On  the  other  hand,  there  are  very  plain  observations  to  show  that  the 
disease  is  communicable  by  substances  contained  in  the  excrements  of  the 
patient.  It  is  unnecessary  to  adduce  particular  examples  of  this  fact. 
Almost  every  instance  of  the  transmission  of  the  disease  cited  in  these 
pages  in  illustration  of  the  various  points  of  the  etiology  of  enteric  fever, 
is  also  an  illustration  of  this  point.  Persons  who  do  not  breathe  an  at- 
mosphere charged  with  the  emanations  from  sewers,  privies,  dung-hills,, 
which  contain  the  dejections  of  typhoid-fever  patients,  nor  drink  water 
polluted  with  soakage  from  similar  sources,  nor  handle  linen,  bedding,  or 
other  substances  defiled  with  such  dejections  in  a  decomposing  state,  are 
not  liable  to  contract  the  disease,  no  matter  to  what  extent  they  are 
brought  into  personal  relations  with  patients  suffering  from  it.  Entericr 
fever  is  therefore  indirectly,  but  not  directly,  contagious. 

4.  TJie  germ  of  enteric  fever  is  not  ca2yable  of  producing  the  disease 
in  other  perso?is  in  its  fresh  state,  but  must  xmdergo  certain  changes  out- 
side the  body  before  it  acquires  this  power. 

Hospital  experience,  as  well  as  that  of  those  physicians  in  private 
practice  who  have  given  their  attention  to  the  matter,  conclusively  proves 
that  the  fresh  stools  are  incapable  of  communicating  the  disease.  Neither 
the  attendants  who  empty  the  vessels,  nor  medical  men  who  examine  the 
stools,  nor  the  patients  in  adjoining  beds,  who  are  of  necessity  exposed  to 
the  effluvium  from  them  in  their  recent  state,  are  attacked,  save  excep- 
tionally and  under  circumstances  which  warrant  the  supposition  that 
they  have  also  been  exposed  to  excrement  undergoing  decomposition. 
Yet,  as  has  already  been  shown,  all  these  classes  of  persons  are  liable  to 


142  THE  CONTINUED  FEVERS. 

infection  if  tlie  removal  of  the  dejections  be  delayed  by  reason  of  defec- 
tive sewerage  or  other  causes.  The  changes  take  place  in  soiled  linen, 
the  bedding,  or  upon  the  surface  of  the  patient's  body,  if  the  liquid  dejec- 
tions are  not  removed;  but  they  take  place  with  greater  activity  in  drains, 
privies,  or  upon  ground  saturated  with  organic  substances,  where  the 
dejections  are  collected  together.  It  is  in  this  manner  that  a  single  per- 
son ill  of  enteric  fever,  brought  to  a  house  or  locality  previously  free  from 
the  disease,  may  become  the  means  of  indirectly  infecting  many  others. 

At  this  point  there  arises  a  question  of  the  greatest  practical  impor- 
tance. It  is  this  :  Within  what  time  do  the  germs,  innocuous  at  first, 
acquire  their  infecting  properties?  Unfortunately,  the  facts  upon  Avhich 
to  establish  a  positive  reply  to  this  question  are  wanting.  It  is  probable 
that  the  time  is  very  short.  The  fact  that  washerwomen  frequently  con- 
tract the  disease  from  handling  the  clothing  of  patients — a  fact  confirmed 
by  numerous  observers — would  indicate  that  the  development  by  which 
the  germ  assumes  its  power  of  infecting  is  very  rapid,  for  such  articles  are 
rarely  retained  any  considerable  length  of  time. 

Dr.  Cay  ley  states  that  at  the  Middlesex  Hospital  it  was  formerly  the 
custom  to  keep  the  stools  of  cases  of  enteric  fever,  which  the  physician 
wished  to  inspect,  in  pans  which  were  kept  in  the  water-closets  of  the 
wards.  The  time  during  which  these  stools  were  kept  rarely  exceeded 
twelve  hours  ;  nevertheless,  several  instances  occurred  in  which  patients 
using  these  closets  contracted  the  disease.  If  these  reserved  stools  were  the 
cause  of  the  infection,  the  period  within  which  the  contagious  properties 
became  developed  in  them  could  not  have  been  longer  than  twelve  hours. 

The  time  is  certainly  short,  and  it  is  impossible  to  overrate  the  impor- 
tance of  prompt  measures  to  render  the  stools  inert  by  disinfection,  or  by 
the  action  of  "  powerful  decomposing  chemical  agents,"  as  suggested  by 
Budd,  and  their  efficient  removal  to  localities  in  which  they  are  little 
likely  to  do  harm. 

Enteric  fever,  in  view  of  the  fact  that  it  is  communicable  from  the 
sick  to  the  well  only  after  its  specific  germ  has  undergone  certain  changes 
outside  the  body,  belongs  to  the  class  of  miasmatic-contagious  diseases, 
as  defined  by  Liebermeister.' 

5.  Tlie  germ  of  enteric  fever  retains  its  activity,  iti  favorable  situa- 
tions, for  a  long  time. 

Alurchison  informs  us  that  he  has  met  with  several  instances  where 
single  cases  of  enteric  fever  have  originated  in  the  same  house,  3'ear  after 
year,  without  traceable  importation  of  the  poison. 


'See  Ziemssen's  Cyclopasdia.  vol.  i.,  p.  27  et  seq.  I  have  employed  this  term  in 
reference  to  catarrhal  fever  and  cerebro-spinal  fever,  in  a  Bomewhat  different  and 
more  familiar  sense. 


ENTERIC  OR  TYPHOID  FEVER,  143 

•'  For  iustance,  six  cases  were  admitted  from  a  single  house  into  the  London  Fever 
Hospital:  one  in  June,  1849;  one  in  October,  1851;  one  in  February,  1854;  one  in 
November,  1855  ;  one  in  November,  1856  ;  and  a  sixth  in  July,  1857." 

Ur.  Cayley  mentions  an  instance  in  which  an  interval  of  two  years 
passed  without  any  fresh  importation  of  the  poison,  yet  a  new  case  arose. 

Such  cases  as  these  speak  strongly  in  favor  of  the  prolonged  con- 
tinuous existence  of  the  poison  ;  but  they  are  to  some  extent  open  to  the 
objection  that  infection  may  have  occurred  in  some  other  than  ti\e  sus- 
pected manner,  and  have  been  overlooked.  To  the  following  example, 
cited  from  Dr.  von  Gietl,  this  objection  cannot  be  urged. 

"  A  villager,  vi^ho  had  contracted  typhoid  fever  at  Ulm,  returned  to  her  native  vil- 
lage, a  place  where  typhoid  had  not  existed  for  many  years.  The  excrements  of  this 
person  were  thrown  on  the  dunghill.  Several  weeks  later  live  persons  were  employed 
to  remove  this  dunghill.  Of  these  five,  four  were  attacked  with  typhoid  fever,  and 
one  with  gastric  symptoms  and  swelling  of  the  spleen.  The  excrements  of  these  five 
persons  were  buried  deep  in  the  dunghill.  Nine  months  later  two  persons  were  em- 
ployed in  completely  removing  this  dunghill ;  one  of  them  was  attacked  with  typhoid 
and  died  of  it." 

Here,  certainly,  is  a  continuous  existence  of  many  months,  during 
which  the  poison  fully  retained  its  activity.  I  am  disposed  to  regard  the 
well-known  outbreak  at  the  school  at  Clapham,  already  related,  as  a  fur- 
ther illustration. 

6.  There  is  reason  to  believe  that  the  poison  of  enteric  fever  is,  in 
favorable  situations,  capable  of  reproducing  itself  outside  of  the  human 
body. 

Such  situations  are  those  where  decomposing  animal,  and  particularly 
fecal  matters,  are  massed  together,  as  cesspools,  sewers,  drains,  dung- 
heaps,  or  wet  manured  soils.  In  such  places  the  excrement  of  a  single 
patient  may  establish  the  focus  of  a  local  epidemic.  It  seems  impossible 
to  explain  this  fact  except  upon  the  hypothesis  of  the  reproduction  of 
the  infecting  germs  in  such  situations.  Indeed,  there  is  good  reason  to 
believe  not  only  that  they  grow  and  multiply  enormously  in  localities  of 
this  kind,  but  that  they  also  undergo  a  like  increase,  under  some  circum- 
stances, in  water  itself. 

In  the  epidemic  at  Lausanne,  the  dejections  of  two  cases  (for  the  boy 
is  said  to  have  sickened  in  August,  probably  at  about  the  time  the  epi- 
demic arose)  mingled  with  a  running  stream,  the  waters  of  which  were 
used  to  irrigate  extensive  meadows,  and  which  thence  percolated  by  a 
long  underground  way  to  the  spring  which  supplied  the  village,  were 
capable  of  infecting  a  large  number  of  persons.  The  germs  must,  in  this 
instance,  have  undergone  an  enormous  increase  in  numbers,  or  else  the 
poison  of  typhoid  fever  is  capable  of  retaining  its  activity  in  an  extreme 
state  of  dilution. 


144  THE    CONTINUED    FEVERS. 

Compare  also  a  recent  epidemic  at  Caterham  and  Redhill,  of  which  the 
particulars  are  related  by  Dr.  Cayley  : 

"  This  outbreak  was  clearly  shown  by  Dr.  Thome  to  have  been  caused  by  the  con- 
tamination of  the  water  of  the  Caterham  Water  Company  by  the  alvine  discharges  of 
a  single  workman  suffering  from  ambulent  typhoid,  who  was  engaged  in  the  construc- 
tion of  a  new  adit.  If  any  necessity  arose  for  the  workmen  to  relieve  themselves 
during  their  spell  of  work  below,  which  lasted  from  eight  to  twelve  hours  and  there 
should  be  any  difficulty  or  delay  in  their  being  drawn  up  to  the  surface  it  was  ar- 
ranged that  they  should  use  the  buckets  which  were  employed  in  raising  the  chalk. 

"  This  man,  it  appears,  had  very  copious  diarrhoea,  and  had  to  relieve  his  bowels 
two  or  three  times  during  each  spell,  but  he  positively  denied  ever  having  passed  his 
motions  in  the  adit  without  waiting  for  a  bucket.  But,  nevertheless,  there  were  un- 
doubted means  by  which  his  evacuations  could  have  found  their  way  into  the  water, 
for,  as  the  buckets  were  drawn  up,  their  oscillations  caused  them  to  strike  against  the 
sides  of  the  shaft,  and  some  of  the  contents  would  so  be  shaken  out  and  fall  over  a 
stage  in  the  water  below.  And  he  also  stated  that  his  motions  were  so  liquid  that  the 
buckets,  which  were  also  used  to  lower  materials  used  in  the  construction  of  the  adit, 
must  have  been  stained  with  them.  Here,  then,  we  have,  in  all  probability,  only  some 
splash  ings  of  typhoid  stools  mixed  with  a  veiy  large  body  of  water — a  proportion  of 
the  most  extreme  minuteness— and  yet  the  water  so  contaminated  gave  typhoid  fever 
to  three  hundred  and  five  persons." 

7.  That  it  remams  suspended  in  water,  and  may  he  conveyed  in  it^ 
and  that  it  usually  finds  access  to  the  body  in  that  way,  has  already  been 
abundantly  demonstrated.  The  following  examples  are  peculiarly  in- 
structive : 

"Epidemic  in  Stuttgart,  1872.  The  meadows  from  which  a  portion  of  the  Stutt- 
gart aqueduct  receives  its  supply  were,  in  the  beginning  of  the  winter  of  1871-72, 
thickly  manured  with  the  matters  taken  from  the  city  sewers.  In  January  there  was 
a  thaw  with  rain,  nnd  the  water  of  this  aqueduct  became  of  a  yellow  color,  with  an 
offensive  smell.  This  was  not  produced  by  inorganic  substances,  and  examination 
showed  the  presence  of  large  quantities  of  organic  matter.  The  water  reduced  a 
permanganate  solution  as  much  as  would  a  mixture  of  pure  water  with  one-half  per 
cent,  of  urine.  In  February  an  epidemic  broke  out,  in  the  portion  of  the  city  sup- 
plied by  this  aqueduct,  so  severe  that  there  was  an  average  of  one  typhoid  patient  for 
every  two  houses.  In  a  neighboring  district,  partly  supplied  with  water  from  the 
Fame  aqueduct,  there  was  an  average  of  one  patient  to  every  ten  houses.  In  the  rest 
of  the  city  the  disease  was  not  more  frequent  than  at  ordinary  times,  averaging  one 
case  to  every  one  hundred  and  forty-four  houses." 

"Epidemic  in  the  '  Soherenfabrik,'  in  Basle,  1867.  In  a  collection  of  houses  situ- 
ated at  some  distance  from  the  city,  of  which  the  inhabitants  numbered  about  one 
hundred  and  fifty,  mostly  girls  of  thirteen  to  seventeen  years  old,  there  were  no  cases 
of  typhoid  during  the  severe  epidemic  in  Basle,  in  1865-6G.  In  the  year  1867,  when 
the  epidemic  had  subsided  in  the  city,  a  single  case  appeared  in  January,  a  second 
case  in  February,  and  in  May  a  large  number,  so  that,  within  twenty-two  days,  thirty- 
six  persons  were  attacked  with  typhoid  fever,  and  many  others  with  febrile  and 
afebrile  abdominal  catarrh.  It  was  shown  that  the  well  from  which  the  drinking- 
water  was  drawn  was  fed  from  a  canal  into  which  emptied  the  privy.  Eighteen  days 
after  the  use  of  this  water  was  forbidden  there  were  no  more  new  cases.     A  little 


ENTERIC    OR    TYPHOID    FEVER,  145 

later,  three  more  cases  occiarred  in  persons  who  had  probably  disobeyed  and  drunken 
of  the  water.     After  the  well  was  completely  closed,  there  were  no  more  cases." 

A  careful  study  of  these  and  other  cases  already  given  shows  that  it 
is  chiefly,  perhaps  only,  in  water  that  is  confined  in  close  situations,  that 
the  poison  retains  its  activity  for  a  considerable  length  of  time,  or  is 
capable  of  reproducing  itself.  In  large  bodies  of  open  water,  and  in  run- 
ning streams,  it  is  probably  speedily  rendered  inert. 

Within  recent  years  a  number  of  epidemics  of  enteric  fever  have  been 
traced  to  milk,  supplied  from  dairy-farms  where  cases  of  the  disease  have 
led  to  the  contamination  of  the  wells  from  which  the  water  used  for 
washing  the  milk-cans,  and  perhaps  also  for  the  dishonest  dilution  of  the 
milk,  has  been  obtained. 

The  following  is  among  the  more  recent  of  such  outbreaks: 

"At  Southport,  one  case  of  typhoid  after  another  was  announced  to  the  munici- 
pal authorities,  until  in  about  two  weeks  a  total  of  twenty  eight  was  reached.  Such 
a  rapidly  invading  epidemic  demanded,  of  course,  energetic  measures  for  its  repression, 
and  a  careful  inspection  of  the  various  dwellings  in  which  the  victims  had  been  at- 
tacked was  undertaken.  The  health  officers  found,  however,  to  their  surprise,  that 
with  two  trifling  exceptions  these  premises  were  all  in  good  sanitary  condition ;  but  fur- 
ther investigation  disclosed  the  fact  that  in  every  instance  milk  had  been  served,  to  the 
families  in  which  the  typhoid  fever  had  occurred,  from  a  particular  dairy  some  miles 
distant,  and  upon  the  grounds  of  this  dairyman  was  discovered  a  well  horribly  polluted 
with  soakage  from  a  filthy  cesspit  near  it.  In  the  words  of  the  chairman,  "Chemical 
analysis  showed  that  it  was  nothing  but  liquid  sewage,  and  calculated  to  spread  disease 
wherever  its  influence  extended,"  and  the  proof  that  this  foul  infecting  material  had 
been  accomplishing  the  work  for  which  it  was  so  well  "  calculated  "  is  met  with  in  the 
circumstance  that,  on  stopping  the  milk-supply  from  this  dairy,  the  epidemic  ceased  to 
spread,  although  not  before  two  of  the  cases  previously  attacked  had  resulted  fatally. ' ' ' 

It  is  not  here  expressly  stated  that  enteric  fever  cases  existed  upon 
the  farm  in  question,  but  the  argument  thus  far  followed  has  been  in 
vain,  if  a  specific  germ  was  not  in  fact  the  cause  of  the  specific  disease 
which  the  tainted  milk  produced. 

8.  The  lioison  of  enteric  fever  is  also  propagated  by  the  atmosphere, 
and  reaches  the  blood  by  means  of  the  inspired  air. 

The  common  experience  of  all  physicians  sustains  this  proposition. 
Liebermeister  states  that  in  the  hospital  at  Basle,  where  infection  by 
drinking-water  could  be  excluded,  he  often  saw  cases  of  typhoid  arise 
under  conditions  which  seemed  to  exclude  every  other  mode  of  infection 
except  by  the  air. 

The  case  of  the  villager  narrated  above  (p.  143),  whose  dejections, 
buried  in  a  dung-hill,  gave  rise  to  the  disease  in  those  who  disturbed  it 
some  time  afterward,  has  been  cited  with  reason  to  prove  that  the  germs 

'  Medical  News  and  Abstract,  January,  188t. 
10 


146  THE  CONTINUED  FEVERS. 

may  be  inhaled.  It  is  in  this  manner  that  tlie  disease  is  contracted  by 
washerwomen  from  soiled  linen.  Dr.  Murchison  narrates  the  particulars  of 
an  outbreak,  in  which  twenty-eight  boys  out  of  thirty-six  were  attacked 
in  a  school  in  the  succession,  and  with  an  intensity,  corresponding  to  the 
degree  of  their  exposure  to  the  emanations  from  an  untrapped  drain  in 
a  passage-way  leading  to  the  scliool-room. 

In  cities  where  the  character  of  the  water-supply  precludes  infection 
by  means  of  drinking-water,  as  in  Philadelphia  and  New  York  at  the 
present  time,  sporadic  cases  of  enteric  fever  are  doubtless,  in  the  great 
majority  of  instances,  due  to  the  inhalation  of  the  poison.  The  origin  of 
such  cases  is  usually  difficult,  often  impossible,  to  trace. 

It  is  probable  that  the  poison,  being  in  the  form  of  solid  particles  of 
extreme  minuteness,  is  arrested  upon  the  tongue  and  pharyngeal  mucous 
membrane,  and  swallowed  with  the  saliva.  Some  writers  upon  the  sub- 
ject entertain  the  opinion  that  it  may  also  reach  the  blood  by  way  of  the 
respiratory  mucous  surfaces — a  view  that  is  rendered  very  probable  by  the 
readiness  with  which  relatively  coarse  particles  of  matter  of  a  different 
kind  find  their  way  into  the  tissues  of  the  lung,  in  the  case  of  miners  and 
other  workmen,  although  the  constant  intestinal  lesion  has  been  adduced 
to  uphold  the  view  that  the  poison  enters  the  system  by  the  way  of  the 
alimentary  canal.  Whatever  the  channels  by  which  it  finds  access,  it 
manifests  a  constant  predilection  for  the  lymph- follicles  of  the  ileum. 

Enteric  fever  is  pre-eminently  an  endemic  disease.  The  larger  cities 
of  the  moderate  temperate  zone  are  never  free  from  it.  The  poison  is 
propagated  continuously.  From  the  patient  it  finds  its  way  into  localities 
suited  to  its  growth  and  reproduction,  and  from  such  localities  it  gains 
access,  by  means  of  the  air,  the  drinking-water,  or  other  ingesta  again 
into  the  human  body.  The  dangers  of  infection  by  drinking-water  are 
reduced  to  a  minimum  where  the  supply  of  water  is  drawn  directly  by 
means  of  distributing  pipes  led  into  the  houses,  from  large  common  reser- 
voirs adequately  guarded  against  defilement  and  placed  at  such  a  height 
as  to  escape  contamination  by  soakage  from  the  neighboring  cesspools. 
These  dangers  arise,  however,  wherever  cisterns  or  tanks  are  introduced 
into  houses,  and  especially  into  such  houses  as  are  provided  with  water- 
closets  which  are  supplied,  even  indirectly,  from  the  same  cistern  as  the 
common  wash-  or  drinking-water.  It  very  often  happens  that  the  over- 
flow pipe  of  the  tank  acts  as  a  ventilating  shaft  to  the  sewer.  Notwith- 
standing all  the  precautions  of  the  most  advanced  knowledge  of  the 
draining  and  ventilating  of  houses,  it  is  manifest  that  the  complex  system 
of  continuous  drainage  necessary  in  cities  is  occasionally  conducive  to 
house  and  local  epidemics  of  enteric  fever,  as  well  as,  to  a  less  degree,  of 
others  of  the  acute  infectious  diseases.  The  efficiency  of  such  arrange- 
ments, for  the  most  part,  explains  the  much  more  common  occurrence  of 
single  cases  rather  than  groups  of  cases.     A  case  of  the  disease  is  incapa- 


ENTERIC    Oli   TYPHOID    FEVER.  147 

ble  of  infecting  those  about  it,  if  the  dejections  be  promptly  disinfected 
and  swept  away  into  well-constructed  sewers  ;  but  it  becomes  a  focus  of 
infection  if  the  excrement  be  neglected  or  retained.  Hence,  local  epi- 
demics are  much  more  common  in  villages  and  small  towns,  while  spora- 
dic cases  are  constantly  present  in  crowded  neighborhoods  and  large 
cities,  A  sporadic  case  may,  however,  become  the  means  of  infecting 
persons  at  a  distance,  who  drink  the  water  or  breathe  the  air  polluted 
with  the  outpourings  of  the  sewer  into  which  the  typhoid  stools  are 
thrown.  It  is  not  vincommon  for  the  disease  to  arise  on  board  vessels  ly- 
ing in  rivers  at  points  where  the  sewers  of  large  cities  empty.  It  is  in 
this  sense  that  the  sewers  may  be  spoken  of  as  a  continuation  of  the  dis- 
eased intestine. 

It  would  follow,  from  the  foregoing  considerations  of  the  nature  of  its 
cause,  that  enteric  fever  is  a  disease  essentially  localized  in  its  distribu- 
tion. Such  is  in  fact  the  case.  The  specific  cause  is  to  be  found  every- 
where, and  is  readily  capable  of  transportation  from  place  to  place,  but  it 
lurks  in  dark,  neglected  corners  and  about  the  foul  ways  of  men's  dwell- 
ing-places, and  creeps  along  with  oozing  filth,  crawling  into  wells  and 
springs,  and  hiding  itself  in  the  ground,  choosing  now  a  victim,  and  again 
a  group  of  them,  but  never  giving  rise  to  pandemics,  or,  in  the  wide  sense, 
even  epidemics,  as  do  the  poisons  of  typhus,  cholera,  or  relapsing  fever. 
The  most  extended  epidemics  of  enteric  fever  extend  over  certain  quarters 
of  a  city,  or  a  large  town,  or  a  limited  section  of  country,  and  are  always 
made  up  of  other  distinct,  local,  circumscribed  outbreaks  or  endemics. 

Clinical  History. 

The  course  of  enteric  fever  has  been  variously  divided  by  those  de- 
scribing it  into  artificial  stages  in  accordance  with  the  relative  importance 
they  have  attached  to  the  symptoms  or  the  lesions.  The  older  authors 
distinguished  a  stadium  prodromorum^  a  stadium  incretnenti,  extending 
over  the  first  week,  a  stadium  acmes  vel  fastigii,  extending  over  the 
second  week  and  part  of  the  third,  and  a  stadium  decreme?iti  beginning 
at  the  end  of  the  third  week. 

At  a  later  period  it  became  customary  to  divide  the  disease  into  two 
stages:  the  first  covering  the  time  of  the  development  of  the  attack;  the 
second,  the  period  of  improvement  and  convalescence.  Under  this  ar- 
rangement the  first  three  weeks  of  the  disease  are  embraced  in  the  first 
stage,  the  last  week  and  the  whole  period  until  the  restoration  of  health 
in  the  second. 

Others,  again,  have  divided  the  course  of  the  disease,  after  the  stage 
of  incubation,  into  a  stage  of  invasion,  a  stage  of  glandular  enlarge- 
ment, referring  to  the  intestinal  lesion,  a  stage  of  ulceration  or  sloughing, 
a  stage  of  lysis,  and  the  convalescence. 


148  THE   CONTINUED    FEVEKS. 

Wunderlich  determined,  by  extended  observations  of  the  temperature 
in  enteric  fever,  that  the  febrile  movement  has,  in  uncomplicated  cases, 
a  typical  course,  and  that  the  deviations  from  this  course,  in  obscure  and 
complicated  cases,  are  not  such  as  to  prevent  a  diagnosis  from  the  tem- 
perature-curve alone,  if  the  physician  be  familiar  with  the  ordinary  devia- 
tions. In  well-marked  uncomplicated  cases  the  entire  duration  of  the 
fever  is  from  three  to  four  weeks.  This  time  may  be  divided,  with  refer- 
ence to  the  temperature,  into  four  periods,  to  eacli  of  which  belongs  a 
special  fever-curve,  and  each  of  which  lasts,  in  general  terms,  about  a 
week.  In  accordance  with  these  facts,  the  German  observers  divide  the 
course  of  the  disease  into  six  periods,  namely,  the  stage  of  prodromes,  the 
first,  the  second,  the  third,  and  the  fourth  weeks,  and  the  period  of  con- 
valescence. It  is  to  be  borne  in  mind,  however,  that  these  periods  may 
be  modified  by  complications  or  by  treatment,  and,  that  by  sequels,  or 
relapses,  the  duration  of  the  disease  may  be  indefinitely  prolonged. 

A  stage  of  prodromes  usually  precedes  the  onset  of  the  fever,  which  is 
so  insidious  that  the  patient,  in  most  instances,  is  unable  to  designate  the 
day  of  its  commencement,  although  his  mind  and  memory  may  be  still 
alike  unimpaired.  The  patients  are  weary  and  complain  of  a  general  feel- 
ing of  malaise  with  vertigo,  headache,  especially  in  the  forehead,  often  in- 
creasing toward  night.  The  sleep  is  broken  and  unrefreshing.  Muscular 
pains  may  also  be  the  subject  of  complaint.  Sometimes  there  are  uneasy 
abdominal  pains  with  diarrhoea,  and  if  diarrhoea  be  not  at  first  present,  it 
is  often  induced  by  the  purgative  medicines  to  which  the  patients  are  apt 
to  have  recourse.  At  the  same  time  the  patient  is  silent  and  indisposed 
to  exertion;  his  expression  is  dull;  his  appetite  is  poor;  his  tongue 
swollen,  and  often  heavih^  coated.  This  period  has  a  duration  of  from  five 
to  ten  days,  sometimes  it  is  even  longer.  It  gradually  merges  into  the 
declared  disease.  Sometimes  slight,  irregular  chills,  or  repeated  attacks 
of  chilliness,  mark  the  beginning  of  the  fever.  In  other  cases  the  fever  is 
preceded  by  an  attack  resembling  intermittent  fever.  The  course  of  the 
fever,  however,  soon  becomes  remittent,  and  the  characteristic  symptoms 
of  enteric  fever  are  developed.  Such  cases  are  oftenest  encountered  in 
malarial  districts.  In  rare  instances  the  disease  begins  abruptly  without 
prodromes,  being  ushered  in  with  a  chill  followed  by  high  fever.  If  there 
be  no  definite  phenomenon  of  this  kind  from  which  to  date  the  beginning 
of  the  attack,  it  is  customary  to  reckon  it  from  the  day  on  which  the  pa- 
tient was  obliged  to  discontinue  work  or  take  to  his  bed.  Hence,  as  Lie- 
bermeister  has  pointed  out,  the  beginning  of  the  disease  may,  in  conse- 
quence of  the  determined  character  of  the  patient,  be  dated  several  days 
too  late. 

The  frst  xceek. — The  attack  is  to  be  regarded  as  beginning  with  the 
first  chilliness  or  the  first  temperature  rise.  The  fever  steadily  increases, 
but  is  distinctly  remittent  in   type,  the  exacerbations  occurring  in  the 


ENTERIC  OR  TYPHOID  FEVER.  149 

afternoon  or  evening,  and  the  remissions  in  the  morning.    The  rise  in  tem- 
perature, although  steady,  is  gradual,  the  morning  remission  of  the  first 
four  or  five  days  being  decidedly  less  in  extent  than  the  evening  exacerba- 
tion of  the  previous  day,  so  that,  by  the  evening  of  the  fifth  day,  the 
temperature  reaches  the  neighborhood  of  40°  C.  (104°  F.).     The  skin  is 
usually  dry  and  hot  ;  sometimes,  however,  especially  in  the  early  part  of 
the  day,  it  is  moist  or  even  bathed  with  sweat.     The  patient,  with  the 
increased  fever  of  the  latter  part  of  the  day,  not  rarely  experiences  sensa- 
tions of  chilliness,  which  are  followed  by  flushing  of  the  face  and  an  in- 
creased sense  of  feverishness.     The  symptoms  of  the  prodromic  stage  are 
intensified.     The  headache  is  violent.     It  is  sometimes  confined  to  the 
frontal  regions,  sometimes  felt  in  all  parts  of  the  head.     More  rarely  the 
focus  of  head-pain  is  in  the  occipital  region.     Epistaxis  not  infrequently 
occurs  ;  it  is  usually  slight,  often  not  exceeding  a  few  drops  ;  at  other 
times  the  amount  is  considerable.     The  patient  feels  tired,  and  at  this 
period  of  the  disease  is  usually  obliged  to  keep  his  bed.     If  he  rises  for 
any  purpose,  his  limbs  tremble  from  sheer  weakness,  and  he  is  often  so 
dizzy  that  he  is  obliged  to  be  supported.     His  expression  is  dull,  but  by 
no  means  approaches    the    heavy,  stupid    look  that    is   characteristic   of 
typhus.    He  is  silent,  disinclined  to  mental  exertion;  but,  when  roused,  his 
mind  is  usually  clear  and  his  memory  good.     It  is  not,  however,  always 
easy  to  fix  his  attention.     He  sleeps  restlessly  and  is  disturbed  by  dis- 
agreeable dreams.     Between  sleeping  and  waking  there  is  slight  delirium. 
The  lips  are  parched  and  dry  ;  the  tongue  is  at  first  moist,  its  mucous 
membrane  swollen,  covered  with  a  whitish  yellow  fur,  sometimes  thin, 
sometimes  thick  and  creamy;  its  margin  and  tip  are  red.     After  a  time 
it  becomes  drier  and  is  no  longer  swollen  ;  the  coating  flakes  off  alto- 
gether, or  remains  only  in  irregular  streaks  or  patches.     When  protruded 
it  often  trembles.     The  tonsils  and  the  pharyngeal  mucous  membrane  are 
in   many  cases    also   swollen  and   red.     Appetite    is   lost,  thirst  is  aug- 
mented.     In    many   instances   diarrhoea   continues   from    the    prodromic 
period;  in  the  majority  of  cases,  however,  the  bowels  are  at  first  confined, 
and  diarrhcea  sets  in  some  time  in  the  course  of  the  first  week.     There 
are,  in  the  course  of  the  twenty-four  hours,  several  thin,  brownish  stools, 
feculent  in  character,  unattended  by  pain,  and  usually  without  tenesmus. 
Not   infrequently  diarrhcea    is   absent  in   the  first  week,  or  even  slight 
throughout  the  attack.     In  such  cases,  however,  laxative  drugs  act  with 
unusual  energy.      Toward  the  close  of  this  period  there  is  some  fulness 
of  the  abdomen,  or  it  may  be  decidedly  distended,  and  even  tense.     It  is 
tender  to  pressure,  particularly  in  that  part  of  the  surface  corresponding 
to  the  ileo-cfBcal  region,  and  upon  palpation  gurgling  is  produced.     This 
sign  is  not,  however,  of  diagnostic  importance,  as  it  is  encountered  in 
other  diseases  attended  by  intestinal  catarrh.     At  this  time  the  spleen 
can  be  shown  in  most  cases,  upon  physical  examination,  to  be  enlarged. 


150  THE    CONTINUED    FEVERS. 

Sometimes  its  border  may  be  also  discovered  upon  palpation,  but  the 
abdominal  distention  usually  renders  this  impossible.  The  urine  is  com- 
monly diminished  in  quantity,  and  occasionally  shows  a  faint  reaction 
upon  testing  for  albumen;  the  urea  is  increased,  the  chlorides  diminished. 
In  some  cases  the  characteristic  eruption  appears  upon  the  last  day  of  the 
first  week.  The  conjunctivae  are  not  injected,  nor  is  the  face  dusky,  as  in 
typhus,  but  commonly  there  is  a  circumscribed  pink  flush  over  one  or 
both  cheek-bones,  like  the  flush  of  hectic,  and,  like  it,  deeper  toward  the 
latter  part  of  the  day.  At  this  period,  upon  auscultation,  a  few  scattered, 
coarse,  mucous  rales  may  be  detected  posteriorly. 

Tlie  second  week. — The  fever  remains  continuous  at  about  the  same 
height  reached  at  the  close  of  the  first  week,  although  in  severe  cases  it 
may,  at  this  time,  rise  slightly  higher.     The  skin  is  hot  and  dry,  the  ex- 
pression duller,  the  flush  deeper  and  more  continuous,  the  countenance 
sometimes  slightly  dusky.    In  the  course  of  this  period,  and  usually  about 
the  tenth  day,  the  headache  greatly  diminishes  or  ceases  altogether.    The 
mental  condition  is  now  peculiar  and  characteristic  of  the  disease.     The 
patient  is  somnolent,  but  has  no  soun^  sleep,  either  in  the  night  or  day. 
He  is  indifferent,  apathetic.     It  is  difficult  to  rouse  him.     Partly  on  ac- 
count of  his  mental  condition,  and  partly  on  account  of    his  deafness, 
which  is  now  more  or  less  marked,  he  must  be  spoken  to  loudly  in  order 
to  attract  his  attention.     When  asked  how  he  is,  he  commonly  replies 
that  he  feels  well.     As  a  rule,  if  his  attention  is  fixed,  he  answers  ques- 
tions correctly,  but  in  as  few  words  as  possible.     Muscular  movements 
are  feeble,  tremulous,  and  uncertain.     The  tongue  is  protruded  with  diffi- 
culty, partly  on  account  of  its  dryness,  partly  on  account  of  the  patient's 
indifference  to  what  is  said  to  him.     It  is  red,  fissured,  and  crusted  with 
sordes.    The  patient  lies  upon  his  back,  with  his  eyes  half  closed,  motion- 
less, except  that  he  picks  at  the  bedclothes,  or  makes  feeble,  wandering 
movements  with  his  hands.     There  may  be  subsultus  tendinum,  or  convul- 
sive twitchings  of  special  groups  of  muscles.     At  times,  and  particularly 
toward  night,  he  mutters  incoherently,  and  in  the  night,  or  when  roused, 
there  is  wandering  delirium.     The  urine  and  fieces  are  often  passed  in- 
voluntarily, or  the  urine  may  be  retained.    In  other  cases,  and  particularly 
in  those  attended  by  greatly  elevated  temperature,  the  mental  condition 
is  irritable.     The  delirium  is  active;  it  may  be  furious.     The  patients  are 
disturbed  by  vivid  hallucinations,  they  shout,  attempt  to  get  out  of  bed, 
and  are  restrained  with  difficulty.     Sometimes  the  delirium  alternates  be- 
tween these  two  forms  with  great  rapidity,  and  the  instances  are  not  few, 
in  which  patients,  passing  rapidly  from  a  passive,  indifferent  condition, 
with  muttering  delirium,  into  active  delirium,  have  unexpectedly  sprung 
from  their  beds  and  thrown  themselves  from  the  window.     At  this  period 
of  the  disease  patients  should  never  be  left,  even  for  a  moment,  unat- 
tended. 


ENTERIC  OR  TYPHOID  FEVER.  151 

The  belly  is  now  more  swollen  ;  tenderness  and  gurgling-,  especially  in 
the  ileo-CEecal  region,  are  more  marked.  The  diarrhoea  increases — it  may 
become  profuse  ;  the  stools  are  watery,  of  a  yellowish  brown  or  ochre 
color,  or  they  are  of  a  greenish  color  and  llocculent.  The  latter  appear- 
ance has  been  said  to  resemble  "  pea-soup."  The  urine  often  contains  a 
small  amount  of  albumen.  The  spleen  increases  in  size,  but  its  borders 
can  rarely  be  made  out  by  reason  of  the  abdominal  distention.  The  erup- 
tion, which  may  appear  upon  the  seventh  day,  is  more  commonly  met 
with  in  the  first  half  of  the  second  week.  It  is  characteristic  of  the  dis- 
ease. It  consists  of  isolated,  slightly  elevated,  rose-colored  spots,  which 
disappear  upon  pressure,  and  come  out  in  successive  crops  and  gradually 
fade  away.  These  spots  vary  in  size  from  one  to  three  lines  in  diameter; 
they  are  of  an  irregularly  oval  shape,  and,  upon  their  first  appearance,  in- 
distinctly marginate.  They  vary  in  number  from  a  few,  scattered  over 
the  abdomen  and  lower  portion  of  the  thorax,  to  many  hundred,  dis- 
tributed generally  over  the  body.  As  a  rule  from  five  or  ten,  to  twenty 
or  thirty  may  be  counted  in  well-developed  cases.  They  are  absent  alto- 
gether in  some  of  the  milder  examples  of  the  disease. 

Upon  physical  exploration  of  the  chest,  in  addition  to  the  mucous  rules 
heard  at  an  earlier  period  of  the  disease,  scattered  sibilant  and  subcrepi- 
tant  rales,  evidences  of  the  extension  of  catarrhal  processes  to  the  smaller 
bronchial  tubes,  may  be  detected;  and,  upon  percussion,  we  find  impaired 
resonance  at  the  base  of  the  chest  posteriorly,  commonly  more  marked, 
both  in  extent  and  degree,  upon  one  side  than  upon  the  other.  Cough  is 
often  present,  but  it  is  not  proportionate  to  the  pulmonary  lesions.  It  is 
attended  with  a  scanty  mucous  or  muco-purulent  expectoration. 

The  third  week. — The  fever  changes  from  the  continuous  to  the  remit- 
tent form.  The  morning  remissions  become  more  marked,  although  the 
evening  exacerbations  continue  to  be  nearly  as  high  as  during  the  second 
week.  The  symptoms  of  the  second  week,  however,  remain  unabated,  or 
they  even  increase  until  toward  the  end  of  this  period,  for  it  is  not  until 
that  time  that  the  morning  remissions  begin  to  affect  the  general  condi- 
tion of  the  patient.  It  often  happens  that  the  symptoms  which,  taken 
together,  make  up  what  is  known  as  the  "  typhoid  state,''''  and  which  belong 
to  the  latter  part  of  the  second  and  to  the  third  week,  do  not  attain  their 
full  development  until  some  time  in  the  course  of  the  third  week.  The 
stupor  deepens,  so  that  it  is  often  with  the  utmost  difficulty  that  the  pa- 
tient can  be  aroused.  If  he  can  be  prevailed  upon  to  protrude  his  tongue, 
he  often  fails  to  withdraw  it  until  his  attention  is  again  aroused,  and  he 
is  directed  to  do  so.  He  does  not  ask  for  drink;  but,  when  fluid  is  placed 
in  his  mouth,  he  mechanically  swallows  it.  The  faeces  and  urine  escape  in- 
voluntarily, or  the  urine  is  retained  and  the  bladder  may  become  enor- 
mously distended.  From  day  to  day  he  loses  flesh  and  strength.  He  is 
unable  to  raise  himself  or  even  to  turn  in  bed.     His  tissues  are  wasted  ; 


152  THE  CONTINUED  FEVERS. 

his  muscles  soft  ;  his  cheeks  hollow  ;  the  skin  drawn  tightly  over  his  nose 
and  brow;  his  eyes  sunken;  his  face  dusky  and  faintly  flushed  over  the 
cheek-bones.  The  pulse,  frequent  and  wanting  in  force  throughout  the 
case,  now  becomes  yet  more  frequent  and  more  feeble.  New  crops  of  the 
eruption  continue  to  appear.  iVt  this  time,  over  the  neck,  chest,  and  ab- 
domen, copious  outbreaks  of  sudaniina  make  their  appearance. 

It  is  during  this  period  that  bed-sores  are  apt  to  form  over  the  sacrum 
and  other  parts  of  the  body  subjected  to  pressure,  and  that  other  compli- 
cations, especially  those  of  the  respiratory  organs,  become  developed. 

Tlie  fourth  week. — The  fever  is  now  decidedly  remittent.  The  morn- 
ing and  evening  temperatures  are,  from  day  to  day,  progressively  lower, 
while  the  range  between  the  morning  and  evening  of  each  day,  though 
still  greater  than  during  the  first  week,  tends  steadily  toward  the  normal. 
As  the  defervescence  draws  to  a  close,  the  type  of  the  fever  becomes  dis- 
tinctly intermittent,  complete  apyrexia  being  present  in  the  morning,  and 
a  rise  of  a  degree  or  more  (centigrade)  taking  place  late  in  the  day. 
With  this  decrease  in  temperature  the  condition  of  the  patient  gradually 
ameliorates.  The  stupor  disappears  and  the  other  nervous  symptoms  im- 
prove. The  nights  are  more  tranquil.  There  is  natural  sleep,  out  of  which 
the  patient  awakes  refreshed,  while  the  somnolence  of  the  previous  weeks 
gives  place  to  wakefulness.  He  begins  to  be  conscious  of  his  condition 
and  to  take  an  interest  in  what  transpires  about  him.  The  apathy  and 
silence  of  the  previous  weeks  are  replaced  by  questionings  and  complaints. 
The  tongue  and  gums  become  clean,  the  mouth  moist,  the  difficulty  in 
swallowing  ceases.  The  distention  of  the  belly  diminishes,  the  stools  are 
less  frequent,  darker  in  color,  and  formed.  In  most  cases  constipation 
takes  the  place  of  diarrhoea.  The  appetite  returns  and  thirst  diminishes. 
Upon  percussion,  there  is  found  to  be  progressive  diminution  in  the  area 
of  splenic  dulness.  The  urine  is  limpid  and  more  abundant,  and  not  in- 
frequently the  skin  is  bathed  in  perspiration;  especially  during  sleep. 
The  pulse  gradually  becomes  less  frequent  and  fuller,  particularly  in  the 
early  hours  of  the  day.  The  emaciation,  however,  continues  until  the  di- 
urnal temperature-range  becomes  coincident  with  the  normal,  the  patient 
often  losing  as  much  as  the  sixth  or  seventh  part  of  his  body-weight  dur- 
ing the  course  of  the  disease. 

Convalescence  is  established  with  the  disappearance  of  the  fever.  The 
appetite  is  now  good;  it  may  be  even  keen.  Strength  gradually  returns. 
The  patient  rapidly  gains  weight,  often  several  pounds  in  the  course  of  a 
week,  and  experiences  at  the  same  time  a  sense  of  returning  mental  and 
physical  power;  but,  in  spite  of  this,  he  is  easily  fatigued  by  exertion, 
and  the  convalescence  is  tedious.  It  is  liable  to  be  disturbed  by  compli- 
cations and  sequels.  Even  in  uncomplicated  cases  it  is  often  months  be- 
fore the  patient  fully  regains  his  old  powers  of  endurance  for  mental  and 
bodily  effort.     During  the  early  part  of  the  convalescence  the  patient  is 


ENTERIC  OR  TYPHOID  FEVER.  153 

prone  to  transient  febrile  or  subfebrile  states,  which  may  be  induced  by 
trifling  causes,  such  as  overexertion  in  the  sick-room,  the  visits  of  friends, 
mental  eifort,  or  solid  food.  Liebermeister  states  that  he  has  frequently 
seen  the  first  meal  of  meat  followed  by  an  increase  of  temperature  in  the 
evening.  These  recurrences  of  fever  often  arise  without  discoverable 
cause. 

Occasionally  the  convalescence  is  interrupted  by  a  true  relapse. 

The  foregoing  sketch  is  descriptive  of  a  severe  case,  unmodified  by 
treatment  or  complications,  and  terminating  in  recovery.  The  natural 
history  of  enteric  fever  calls,  however,  for  many  modifications  of  this  de- 
scription. Many  cases  run  a  very  mild  course,  so  that  the  patient  is 
scarcely  confined  to  bed,  and  the  physician  remains  in  doubt  as  to  whether 
the  disease  is  due  to  a  specific  cause.  Others  are  at  first  severe,  but 
speedily  become  mild  in  character,  and  terminate  in  restoration  to  health; 
while  others  still,  in  their  middle  course,  undergo  a  sudden  or  even  fatal 
aggravation.  Striking  modifications  of  the  course  of  the  disease  are  oc- 
casioned by  the  prominence  of  certain  symptoms  or  groups  of  symptoms, 
or  by  the  presence  of  complications  which  may  become  so  serious  as  to 
throw  the  original  disease  into  the  background. 

Analysis  of  the  Principal  Symptoms. 

THE  PHENOMENA   OF   THE   FEVEK. 

The  temper  attire. — The  consideration  of  the  febrile  movement  in  en- 
teric fever  is  of  primary  importance  on  account  of  its  determining  the 
diagnosis,  prognosis,  and  treatment. '  As  has  been  indicated,  in  well- 
marked,  uncomplicated  cases  the  course  of  the  fever  is  typical.  It  may 
be  separated  into  four  periods,  each  of  which  is  characterized  by  a  special 
fever-curve.  These  periods  are  usually  of  about  a  week's  duration,  but 
they  do  not  exceed  five  days  in  many  cases,  and  more  rarely  they  are  ex- 
tended to  eight  or  even  nine  days  (Fig.  8). 

The  typical  course  of  the  fever  is  frequently  disturbed  by  complica- 
tions, and  prolonged  by  sequels  and  relapses. 

Hence,  while  the  average  duration  of  the  fever  is  from  three  to  four 
weeks,  it  is  often  longer,  and  the  febrile  movement  then  differs  in  a  re- 
markable manner  from  the  more  regular  course  of  the  other  acute  infec- 
tious diseases. 

During  the  first  period  there  is  a  rapid,  progressive  increase  of  the 
fever.  This  increase  is  not,  however,  steady.  The  rise  in  temperature  is 
broken  by  daily  morning  remissions  corresponding  to  the  morning  fall  in 
the  diurnal  temperature-cycle  in  health.     It  takes  place  in  a  gradual  zig- 

'  Griesinger :  Das  Fieber  beherrscht  zu  grossem  Theil  die  Situation. 


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ENTERIC    OR    TYPHOID    FEVP:R.  155 

zag,  in  such  a  manner  that  during  the  time  occupied  in  attaining  the 
maximum  it  rises  from  1°-1.5°  C.  (1.8°-2.7°  F.),  from  each  morning  till 
evening,  and  falls  again  from  the  evening  to  the  following  morning  .S**- 
.75"  C.  (.9°-1.3°  F.).  On  the  third  or  fourth  evening  a  temperature  of 
40°  C  (104°  F.)  may  be  reached  or  even  exceeded.  The  daily  rise  begins 
about  noon,  and  is  completed  some  time  between  seven  and  eleven  o'clock 
in  the  evening.  The  fall  begins  about  midnight,  and  the  temperature  is 
lowest,  as  a  rule,  between  six  and  eight  o'clock  in  the  morning.  In  order 
to  make  satisfactory  records  of  the  temperature  in  any  case,  it  is  therefore 
necessary  to  take  two  observations  daily,  one  as  nearly  as  possible  at 
8  A.M.,  the  other  about  9  p.m.  Critical  studies  of  the  temperature  of 
enteric  fever  have  shown  that  a  single  daily  maximum  is  the  rule,  but 
that  in  many  cases  the  diurnal  curve  presents  two  maxima — one  early  in 
the  evening,  and  the  other  about  midday,  usually  of  less  intensity.  The 
highest  evening  temperature  in  the  typical  course  of  the  fever  is  usually 
attained  at  the  close  of  the  first,  or  in  the  beginning  of  the  second  period, 
and  is  as  a  rule  somewhere  between  40°-41.5°  C.  (104°-106.7°  F.).  This 
maximum  is  commonly  observed  upon  one  day  only,  sometimes  on  twO' 
days,  rarely  on  three. 

It  is  very  seldom  that  an  attack  of  enteric  fever  occurring  in  a  healthy 
man,  or  even  an  invalid,  provided  he  be  free  from  fever,  does  not  approxi- 
mate to  the  above  type  in  its  initial  stage.  It  is  still  more  rare,  for  any 
other  form  of  disease  except  enteric  fever,  to  show  a  similar  initial  stage. 
This  course  in  the  first  week  thus  of  itself  alone  possesses  very  great 
value  for  diagnostic  purposes  {Wunderlich'). 

The  second  period  is  characterized  by  a  fever  that  has  been  described 
as  continuous.  This  term  is  not  to  be  understood  as  meaning  that  the 
temperature  remains  the  same  throughout.  If  we  employ  it  in  so  literal 
a  sense,  there  is  no  such  thing  in  the  whole  domain  of  pathology  as  a  con- 
tinuous fever.  As  is  seen  in  the  schematic  representation  of  the  course  of 
the  fever,  the  temperature  is  higher  in  the  evening  and  lower  in  the 
morning,  but  the  diurnal  variations  are  not  greater  than  in  healthy  per- 
sons in  a  state  of  quiet.  No  distinct  remissions  occur.  It  is  only  in  cases 
in  which  the  fever  is  very  high  that  the  temperature-curve  shows  a  morn- 
ing fall  decidedly  less  than  that  which  takes  place  at  the  same  hour  of 
the  day  in  health.  Toward  the  close  of  this  period  the  evening  rise,  ex- 
cept in  very  severe  and  protracted  cases,  often  falls  a  little,  and  at  the 
same  time  the  morning  fall  is  a  trifle  greater. 

The  third  period  is  marked  by  morning  remissions,  which  from  day  to 
day  become  more  distinct,  while  the  evening  exacerbations  attain  the 
height  reached  toward  the  close  of  the  second  period.     The  change  from 

'  On  the  Temperature  in  Diseases.  By  Dr.  C.  A.  Wunderlicli  :  Sydenham  Society's 
Transactions.     London,  1871. 


156  THE  CONTINUED  FEVERS. 

the  continuous  to  the  remittent  type  during  this  period  of  the  disease  is 
usually  a  gradual  one,  but  it  is  not  unfrequently  sudden,  and  is  then 
ushered  in  by  perturbations  of  temperature — often  an  unusually  high 
evening  exacerbation,  followed  by  a  decided  morning  remission.  It  may 
take  place  as  early  as  the  fourteenth  day,  and  when  sudden  it  suggests 
the  critical  perturbations  which  occur  toward  the  close  of  relapsing  and 
typhus  fevers. 

During  the  fourth  period  the  fever  gradually  changes  from  the  remit- 
tent to  the  intermittent  t^'jie.  The  morning  fall  is  each  day  lower  and 
the  evening  rise  a  little  less  decided,  but  the  range  between  them  is  con- 
siderable; so  that,  for  several  days  after  the  morning  temperature  has 
become  normal,  the  evening  shows  marked  fever,  and  upon  the  whole  we 
tind  a  defervescence  of  the  most  gradual  character  (Fig.  9). 

Convalescence  is  not  established  until  the  evening  temperature  ceases 
to  rise  above  the  normal  standard.  In  the  early  days  of  convalescence  the 
temperature  is  often  subnormal,  especially  in  the  morning,  and  it  is  liable 
to  decided  fluctuations  in  consequence  of  slight  causes,  such  as  overexer- 
tion, even  within  the  limits  of  the  bedroom,  excitement,  the  visits  of 
friends,  or  animal  food.  Griesinger  narrates  the  case  of  a  girl,  whose 
fever  had  fallen  to  37.3°  C.  (99.1°  F.)  in  the  morning,  and  to  .38°  C.  (100.4° 
F.)  in  the  evening,  who  ate  sausage.  Her  temperature  rose  that  evening, 
with  general  aggravation  of  the  symptoms,  to  40.5°  C.  (104.9°  F.),  and  did 
not  fall  to  its  former  level  again  until  after  three  days.  Jaccoud  also  re- 
cords a  case  in  which  a  lad,  eighteen  years  of  age,  suffering  from  abortive 
enteric  fever,  was  allowed,  on  the  thirteenth  day  of  his  sickness,  an  egg. 
The  temperature  of  the  previous  evening  was  38.3°  C  (101.5°  F.),  and  on 
the  morning  in  question  37.3°  C.  (99.1°  F.).  The  same  evening  it 
reached  40°  C.  (104°  F.).  Two  days  later  it  had  fallen  to  37.G°  C.  (99.6° 
F.)  in  the  morning,  and  the  patient  was  allowed  to  eat  a  chop  ;  that 
evening  the  temperature  rose  to  40.8°  C.  (105.4°  F.),  and,  while  it  fell  to 
•almost  the  previous  level  on  the  morning  of  the  sixteenth  day,  it  rose 
that  evening  to  40°  C.  (104°  F.),  and  only  resumed  the  regular  curve  of 
the  gradual  defervescence  again  on  the  seventh  day.  Here  the  Jhbris 
carnis,  as  this  distinguished  clinician  terms  this  transient  fever,  lasted 
two  days. 

Those  cases  must  be  looked  upon  as  severe  in  which  the  evening  tem- 
perature steadily  rises,  and  the  morning  fall  diminishes,  in  the  latter  half 
of  the  second  period;  so  also  those  in  which  the  morning  temperature 
does  not,  from  day  to  day,  fall  below  39.5°  C.  (103.1°  F.),  or  in  which  it 
reaches  40°  C.  (104°  F.),  Recovery  rarely  takes  place  after  a  morning 
temperature  exceeding  40.5°  C.  (104.9°  F.),  or  an  evening  temperature 
exceeding  41.75°  C.  (107.15°  F.),  although  occasional  exceptions  to  both 
these  statements  have  been  recorded.  A  persistently  high  temperature, 
in  which  the  difference  between  the  morning  and  evening  range  is  slight. 


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158  THE    CONTINUED    FEVEIiS. 

is  much  more  unfavorable  than  a  temperature  characterized  by  high  even' 
ing  exacerbations  and  considerable  morning  remissions.  In  other  words, 
the  greater  the  regular  daily  fluctuations  of  the  fever,  the  less  severe  is 
it  likely  to  prove. 

A  persistent  elevation  of  temperature,  after  convalescence  is  estab- 
lished, can  only  arise  from  some  complication  or  sequel,  or  from  the  oc- 
currence of  a  relapse. 

A  close  study  of  the  temperature,  of  enteric  fever  in  its  relation  to 
the  symptoms  and  the  lesions  found  after  death,  impresses  us  with  two 
facts  of  great  practical  importance.  Of  these  the  first  is  this:  that  the 
fever,  like  that  of  scarlet  fever  and  of  small-pox,  is  made  up  of  two  dis- 
tinct febrile  movements — first  a  primary  fever,  resulting  from  the  infec- 
tion of  the  tissues  of  the  body  by  the  specific  virus,  and  later  a  second- 
ary, irritative,  or  hectic  fever  caused  by  the  localized  ulceration  of  the 
intestines,  the  formation  of  slough,  and  the  resorption  of  septic  materistls. 

The  second  practical  fact  with  which  we  are  impressed  by  a  near 
examination  of  the  temperature-range  in  a  considerable  number  of  cases, 
is  that  the  balance  between  the  heat-production  and  the  heat- elimination 
in  enteric  fever  is  extremely  unstable — to  use  the  words  of  Dr.  Cayley, 
the  temperature  is  labile.  It  is  quickly  depressed  or  raised  by  causes 
that  would  in  health  have  little  or  no  effect.  Thus,  slight  exertion, 
changes  in  diet,  mental  emotion,  will  often  cause  considerable  transient 
alteration,  not  only  in  the  convalescence,  but  also  during  the  course  of  the 
attack.  The  action  of  remedies  still  further  illustrates  this  point.  Large 
doses  of  quinine  scarcely  affect  the  temperature  in  health,  while  in  enteric 
fever  1.3-2  grammes  (20  or  30  grains)  given  at  once,  or  in  the  course  of 
as  many  minutes,  will  reduce  the  temperature  three  or  four  degrees,  and 
keep  it  down  for  several  hours.  Marked  deviations  from  the  typical 
course  of  the  temperature  are  always  due  to  special  causes  (Fig.  10). 
These  causes  in  many  cases  cannot  be  discovered  by  the  most  searching 
investigation.  On  the  other  hand,  upon  inquiry,  clinical  facts  of  impor- 
tance are  often  discovered,  and  it  is  therefore  the  duty  of  the  physician, 
in  every  case  where  marked  deviations  occur,  to  make  diligent  search  for 
their  cause. 

The  fact  that  we  have  a  primary  and  a  secondary  fever  to  deal  with,  in 
the  course  of  an  ordinary  attack,  is  of  considerable  importance,  both  with 
reference  to  our  knowledge  of  the  pathology  of  the  disease  and  the  treat- 
ment. In  this  respect,  as  I  have  already  pointed  out,  enteric  fever  re- 
sembles small-pox,  in  which  we  have,  first,  the  primary  fever  due  to  the 
direct  action  of  the  poison,  and  lasting  usually  about  three  days;  this  is 
then  followed  by  a  period  of  remission,  to  which  there  finally  succeeds  a 
•secondary  septic  fever  due  to  suppuration.  In  simple  cases  of  scarlet 
fever  the  primary  pyrexia  lasts  five  or  six  days,  and  terminates  commonly 
in  lysis;  but,  where  ulceration  of  the  throat  or  implication  of  the  glands 


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160  THE  CONTINUED  FEVERS. 

occurs,  we  have  a  secondary  septic  fever  coming  on,  either  with  or  with- 
out a  period  of  remission.  On  the  other  hand,  in  typhus  fever,  wliich  is, 
as  a  rule,  unattended  by  suppurative  or  ulcerative  processes,  there  is  no 
secondary  fever,  and  Iflie  long  pyrexia,  due  to  the  specific  cause,  comes  to 
an  end  by  crisis  on  or  about  the  fourteenth  day. 

Between  typhus  on  the  one  hand,  and  scarlet  fever  on  the  other, 
enteric  fever  stands  midway.  It  resembles  typhus  in  the  long  duration 
of  the  primary  fever;  it  resembles  the  protracted  cases  of  scarlet  fever 
in  that  the  secondary  fever  arises  before  the  subsidence  of  the  primary, 
so  that  there  is  no  intervening  period  of  remission.  The  change  is  indi- 
cated, however,  by  the  alteration  in  the  type  of  the  fever,  which  com- 
monly takes  place  during  the  third  period,  and  not  unfrequently  as  early  as 
the  fourteenth  day.  This  change  is,  as  a  rule,  gradual.  It  is  sometimes, 
however,  sudden,  and  is  marked  by  a  distinct  perturbation  of  tempera- 
ture, consisting  often  of  an  evening  rise  in  excess  of  that  of  the  previous 
days.  This  rise  resembles  the  precritical  rise  of  typhus  and  relapsing 
fevers,  and  is  followed  by  a  considerable  morning  fall,  which  is  analogous 
to  the  crisis  of  the  diseases  just  named.  The  analogy  between  enteric 
and  typhus  fevers,  in  respect  of  the  duration  of  the  primary  pyrexia,  is 
made  more  apparent  by  the  fact  that  it  is  at  this  period,  namelj',  about 
the  middle  of  the  third  week,  when  the  type  of  the  fever  becomes  dis- 
tinctly remittent,  that  copious  perspirations  take  place,  together  with 
the  eruption  of  sudamina,  and  that  the  rose-colored  spots  now  cease  to 
appear.  This  resemblance  becomes  still  more  apparent  from  the  con- 
sideration of  the  abortive  forms  of  enteric  fever,  which  are  characterized 
by  sudden  onset,  rapid  augmentation  of  the  temperature  to  a  consider- 
able height,  continued  intense  febrile  movement  until  about  the  four- 
teenth day,  when  defervescence  takes  place  by  rapid  lysis,  altogether 
unlike  the  lingering  decline  of  fever  that  is  characteristic  of  ordinary 
cases.  Such  cases  are  analogous  to  modified  small-pox,  in  which  we  have 
the  primary  fever  well  marked,  but,  in  consequence  of  the  slight  local 
lesions  of  the  skin  and  the  absence  of  suppuration,  there  is  no  secondary 
fever.  It  is  probable  that  they  are  to  be  explained  upon  the  same  ground, 
namelv,  that,  while  the  constitutional  disturbance  due  to  the  primary 
action  of  the  typhoid  poison  is  very  great,  the  intestinal  lesion,  for  some 
unknown  reason — doubtless  dependent  upon  the  constitutional  peculiari- 
ties of  the  patient — is  moderate,  and  the  glandular  deposit  undergoes 
resolution  without  ulceration  or  sloughing.  Dr.  Cayley  suggests  that 
the  cases  of  enteric  fever  that  are  from  time  to  time  described  as  having 
been  cut  short  by  special  remedies  or  plans  of  treatment,  are  really  of 
this  character,  the  observer  having  ascribed  to  the  remedy  changes  which 
are,  in  fact,  natural  phenomena  of  particular  cases  of  the  disease. 


ENTERIC  OR  TYPHOID  FEVER.  101 


SYMPTOMS   KEFEKABLE   TO   THE   CIRCUIjATORY   SYSTEM. 

The  pulse  is  increased  in  frequency.  This  increase  is  directly  and 
chiefly,  in  enteric  fever  as  in  other  febrile  diseases,  dependent  upon  the 
rise  in  temperature.  In  general  terms  the  frequency  of  the  pulse  corre- 
sponds to  the  temperature.  It  rises  during  the  first  week,  continues  high 
during  the  second  and  third,  and  gradually  diminishes  in  frequency  dur- 
ing the  fourth.  It  is  further  true  that  the  daily  variations  in  the  pulse 
run  parallel  with  those  of  the  temperature.  The  pulse  is  less  frequent  in 
the  morning  than  in  the  evening.  The  absolute  frequency  of  the  pulse 
is,  however,  less  in  enteric  than  in  other  fevers.  There  are,  in  fact,  some 
cases  in  which,  although  high  fever  is  present,  the  frequency  of  the  pulse 
does  not,  for  some  part  of  the  time,  exceed  that  of  health;  and  in  the 
mildest  cases  of  enteric  fever,  and  in  cases  of  intestinal  catarrh  without 
fever,  due  to  the  cause  of  enteric  fever,  the  pulse  is  sometimes  less  fre- 
quent than  in  health.  These  facts,  as  Liebermeister  has  pointed  out, 
render  it  probable  that  infection  by  the  poison  has  a  depressing  influ- 
ence upon  the  pulse.  During  the  period  of  the  primary  pyrexia  the  pulse 
does  not  usually  rise  above  120,  and  in  many  cases  it  does  not  exceed  100 
during  the  whole  course  of  the  disease.  In  100  cases  Murchison  ascer- 
tained that  it  exceeded  the  normal  standard,  at  some  time  of  the  fever, 
in  all  but  one;  in  97  cases  it  exceeded  90;  in  85  cases  it  exceeded  100; 
in  70  cases  it  exceeded  110;  in  32  cases  it  exceeded  120;  in  25  cases  it 
exceeded  130;  in  10  cases  it  was  above  140;  and  in  2  above  150.  In  6 
cases  of  100,  the  same  observer  found  the  pulse  fall  to  60;  to  56  in  2; 
and  in  a  single  case  to  52;  in  one  case  under  his  observation  the  pulse 
fell  to  37,  and  never,  throughout  the  whole  course  of  the  disease,  ex- 
ceeded 56,  but  rose  with  convalescence  to  66.  In  severe  cases  the  pulse 
is  apt  to  be  frequent;  and  where  in  an  adult  it  continues  steadily  above 
120,  the  prognosis  becomes  'pro  tanto  unfavorable.  Cases,  however, 
occasionally  prove  fatal,  in  which  the  pulse  does  not  exceed  100. 

The  frequency  of  the  pulse  in  enteric  fever  is,  like  the  temperature, 
readily  modified  by  slight  causes.  Simply  lifting  the  patient  into  the  up- 
right position  may  temporarily  accelerate  the  pulse  from  20  to  30  beats 
per  minute.  During  the  first  week  or  ten  days  of  the  attack  the  pulse 
often  retains  to  a  moderate  degree  the  force  of  health;  but  after  this,  or 
sometimes  earlier,  it  becomes  soft,  compressible,  and  dicrotic.  In  the  ad- 
vanced stages  of  severe  cases  it  may  be  small,  undulating,  irregular,  or 
uncountable.  These  alterations  are  dependent  upon  changes  in  the  heart, 
and  where  death  takes  place  without  complication  at  the  height  of  the 
disease,  it  is  commonly  due  to  heart-failure.  The  following  series  of 
sphygmographic  tracings  show  the  progressive  changes  of  the  pulse  dur- 
ing the  course  of  the  attack  (Figs.  11  to  15). 
]1 


1G2 


THE    CONTINUED   FEVERS. 


The  enfeeblement  of  the  heart,  characteristic  of  enteric  fever  in  its 
later  periods,  and  which  is  a  direct  result  of  the  continued  high  tempera- 
ture, is  manifested  also  by  changes  which  take  place  in  the  impulse,  and 
the  quality  of  the  systolic  sound.    These  in  severe  cases  become  progress- 


FlG.  11.— End  of  First  Week.    Strong  Heart  Action  ;  Moderate  Dicrotism.     Frequency,  lU-1. 


\/V^VAiVAJV\J 


Fig.  12.— Third  Week.     Action  of  Heart  Strong  ;  Marked  Dicrotism.     Frequency,  108. 


Fig.  1.3.- Third  Week.     Action  of  Heart  Weak.     Frequency,  128. 


■piQ    14.— Beginning  Heart  Failure.     Frequency  of  Pulse,  144. 


Fig.  15.— Heart-Failure  after  Profuse  Intestinal  Hemorrhage. 

ively  feebler,  until  the  former  is  imperceptible  and  the  latter  almost  or 
even  quite  inaudible. 

To  the  enfeeblement  of  the  circulation  are  also  referable   a   certain 
amount  of  venous  stasis  showing  itself  in  duskiness  of  the  surface,  and 


ENTERIC    OR   TYPHOID    FEVER.  163 

a  lowering  of  the  arterial  pressure  which  shows  itself  in  diminished  se- 
cretion of  the  urine.  Hypostatic  congestion  of  the  lungs  and  many  other 
complications  arise  from  the  same  cause. 

It  is  to  the  diminished  power  of  the  circulation  also,  that  is  due  the 
marked  coldness  of  the  hands  and  feet  often  occurring  in  severe  caSes, 
while  the  internal  temperature  still  remains  high;  this  condition  is,  there- 
fore, an  important  sign  of  impending  danger  from  failure  of  the  heart. 
To  the  same  cause  we  must  refer  the  common  danger  of  collapse  in  en- 
teric fever.  The  greater  the  weakness  of  the  heart,  the  greater  does  this 
danger  become.  Collapse  may  result  from  various  accidents,  such  as  in- 
testinal hemorrhage,  the  shock  following  perforation,  or  even  a  sudden 
copious  diarrhoea  or  violent  vomiting.  A  sudden  fall  of  temperature, 
either  spontaneous,  or  in  consequence  of  the  administration  of  remedies, 
may  also  occasion  collapse.  Still  more  frequently  collapse  occurs  as  a  re- 
sult of  the  sudden  change  from  the  recumbent  to  the  erect  posture. 
Whatever  its  cause,  collapse  must  be  looked  upon,  under  all  circum- 
stances, as  an  extremely  dangerous  accident  of  the  disease;  for  the  tran- 
sient weakness  of  the  heart  may  quickly  pass  into  complete  paralysis,  and 
so  cause  death.  Liebermei^ster  states  that  the  collapse  which  occurs  in 
consequence  of  a  sudden  fall  of  temperature  is  generally  devoid  of  dan- 
ger, and  may  even  be  a  favorable  sign. 

SY>IPTOMS   KEFERABLE   TO   THE   NEKVOUS   SYSTEM. 

Headache  is  one  of  the  earlier  and  more  constant  symptoms.  The 
proportion  of  cases  in  which  it  is  absent  is  extremely  small.  Louis  found 
it  to  be  absent  in  but  7  out  of  133  cases,  and  Murchison  in  5  out  of  82. 
It  is  probably  not  less  common  in  children  than  in  adults.  It  is  most 
severe  in  the  first  week,  and  by  the  end  of  the  second  week,  or  earlier,  it 
has  usually  ceased.  According  to  Sir  William  Jenner,  it  usually  ceases 
spontaneously  about  the  tenth  day.'*  It  is  commonly  confined  to  the  fore- 
head or  temples,  sometimes  it  extends  over  the  whole  head,  and  more  rarely 
it  is  referred  to  the  occipital  region  alone.  Its  intensity,  usually  mod- 
erate, commonly  increases  toward  evening.  It  is  described  by  patients  as 
dull  rather  than  shooting  or  darting,  although  in  some  instances  I  have 
known  it  to  be  sharp,  piercing,  or  agonizing. 

Slight  vertigo  is  often  associated  with  the  headache  in  the  early  days 
of  the  disease.  As  a  rule,  it  comes  to  an  end  at  the  same  time  as,  or 
before  the  headache;  exceptionally  it  remains  till  the  close  of  the  attack. 

Pains  in  the  back  and  extremities  are  commonly  present  from  the  on- 
set, in  this,  as  in  most  of  the  other  acute  infectious  diseases.  These 
pains  are  sometimes  vague;  at  others  they  are  fixed,  and  aggravated  by 
movement,  like  the  soreness  which  follows  bruises.     Sometimes  the  pa- 


'  On  the  Treatment  of  Typhoid  Fever.     Lancet,  November  15,  1879. 


164  THE    CONTINUED    FEVERS. 

tients  describe  them  as  aching-  or  boring.  Occasionally  they  assume  a 
distinctly  neuralgic  character,  and  sometimes  they  are  confined  to  the 
joints,  and  are  attended  by  tenderness,  slight  swelling  and  redness,  so 
that  they  simulate  acute  rheumatism.  They  usually  subside  some  time 
during  the  second  period  of  the  disease. 

Delirium  occurs  in  a  majority  of  all  the  cases.  Many  cases,  however, 
pass  through  the  whole  course  of  tlie  attack  without  delirium  or  distinct 
impairment  of  the  mental  faculties.  Thus,  Louis  found  that  in  32  out  of 
134  cases  there  was  neither  somnolence  nor  delirium;  and  Murchison 
states  that,  out  of  100  cases  in  which  this  matter  was  noted,  33  passed 
through  the  attack  without  impairment  of  the  intelligence.  These  cases 
do  not  necessarily  belong  to  the  lightest  forms  of  the  disease  ;  of 
Murchison's  33  patients,  3  died — 2  from  perforation  of  the  bowel  and  1 
from  epistaxis;  and  of  Louis'  32  cases,  in  which  there  was  no  delirium, 
8  were  fatal— 6  from  perforation.  These  statistics  are  of  interest  as 
showing  that  no  direct  ratio  exists  between  the  local  intestinal  lesions 
and  the  intensity  of  the  primary  febrile  movement.  For,  although  there 
is  good  reason  to  believe  that  the  disturbance  of  the  nervous  system,  in 
the  early  days  of  typhoid  fever,  is  in  a  measure  directly  due  to  the  action 
of  the  poison,  it  is  certain  that  the  graver  disturbances  of  the  nervous 
system,  among  which  are  to  be  classed  somnolence  and  delirium,  and 
which  in  their  complete  development  constitute  the  "typhoid  state,"  are 
largely  due  to  the  prolonged  high  temperature.  Here,  however,  we  see 
a  considerable  proportion  of  cases,  in  which  the  graver  nervous  symp- 
toms are  absent,  perishing  in  consequence  of  the  extent  and  intensity  of 
the  local  intestinal  lesions. 

The  character  of  the  delirium  varies  greatly;  it  is  often  slight  and 
occasional,  occurring  chiefly  in  the  night-time,  or  upon  waking  from  sleep, 
in  patients  who  are  otherwise  entirely  rational.  This  form  of  delirium 
may  become  active  and  noisy,  and  then,  as  the  patient  becomes  more  pros- 
trate, may  pass  into  the  low,  muttering  delirium,  to  which  the  name  of  ty- 
phomania  has  been  given,  or  into  a  wandering,  fatuous  state,  with  trem- 
bling like  that  of  alcoholism.  Sometimes  the  delirium  is  active  and  noisy 
from  the  first,  the  patient  talking  in  a  loud  voice,  screaming  or  shouting, 
and  being  restrained  with  difficulty.  This  form  of  delirium  may  suddenly 
supervene  upon  either  of  the  others;  it  is  therefore  of  the  utmost  impor- 
tance that  the  patient  should  at  no  time,  after  the  appearance  of  delirium, 
be  left  to  himself,  even  for  brief  intervals.  Exceptionally,  maniacal  de- 
lirium occurs  early  in  the  disease,  and  sometimes  it  is  the  first  symptom 
which  attracts  the  attention  of  the  friends  of  the  patient.  As  a  rule, 
however,  delirium  does  not  commence  before  the  middle  or  end  of  the 
second  week,  upon  the  subsidence  of  the  headache.  In  a  small  proportion 
of  the  cases  it  does  not  appear  till  late  in  the  course  of  the  disease,  and 
lasts  only  a  few  days. 


ENTERIC  OR  TYPHOID  FEVER.  1G5 

In  children  it  occurs  somewhat  earlier  than  in  adults. 

In  many  instances  delirium,  if  mild,  occurs  only  at  night,  and  in  all 
cases  it  is  more  marked  during  the  night-time. 

During  the  first  and  second  periods  of  the  disease  the  patient  is  often 
disturbed  by  loaJcefulness.  This  symptom  is,  however,  much  less  marked 
in  enteric  than  in  typhus  fever. 

Soinnoleace  usually  supervenes  some  time  during  the  course  of  the 
second  week.  It  is  at  first  slight,  but  becomes,  especially  in  severe  cases, 
gradually  more  profound.  It  usually  precedes  delirium,  and,  after  it  is 
established,  alternates  with  periods  of  wakefulness  and  spells  of  delirium. 
The  patient  is  often  dull  and  drowsy  by  day,  and  wakeful,  restless,  and  de- 
lirious during  the  night.  In  cases  of  great  severity  the  somnolence  becomes 
more  constant  and  deepens  into  complete  unconsciousness,  which  lasts  to 
the  termination  of  the  case.     Somnolence  is  met  with  also  in  children. 

Muscular  weakness  is  present,  to  some  extent,  in  all  cases  from  the  be- 
ginning of  the  attack,  and  increases  with  its  progress.  A  large  propor- 
tion of  the  patients  are,  nevertheless,  able  to  assist  themselves,  to  sit  up  in 
bed,  and  even  to  rise  to  stool  throughout  the  whole  course  of  the  attack. 
In  the  mild  forms  of  the  disease,  patients,  although  very  weak,  are  often 
able  to  go  about,  and  it  is  not  rare  to  encounter  walking  cases  as  hospital 
outpatients,  in  the  second  or  third  week  of  the  attack.  In  grave  cases 
muscular  debility  is  very  often  complete. 

Muscular  tremulousness  is  present  in  a  considerable  proportion  of  the 
severer  cases.  The  tongue  trembles  as  it  is  protruded,  the  lips  quiver,  and 
movements  of  the  hands  are  trembling  and  uncertain.  This  phenomenon 
is  most  common  in  those  addicted  to  the  use  of  alcohol,  and  in  old  and  very 
feeble  persons.  More  rarely  it  occurs  in  young  and  temperate  persons, 
and  it  is  occasionally  observed  where  there  is  no  impairment  of  the  men- 
tal faculties. 

Eetentio/i  of  urine  and  involuntanj  evacuations  occasionally  occur. 
They  are  apt  to  take  place  in  those  cases  in  which  the  prostration  is  ex- 
treme. 

Migid  contractions  of  groups  of  muscles  in  the  trunk,  neck,  or  ex- 
tremities, are  met  with  in  a  few  cases.  They  are  most  frequent  in  fe- 
males. In  the  advanced  stages  of  severe  cases,  suhsultus  tendinum,  pick- 
ing at  the  bedclothes,  and  vague  graspings  in  the  air,  are  observed.  In 
such  cases  protracted  hiccougli  may  also  occur.  General  convulsions  are 
rare.  They  occur  with  greater  frequency  in  children  than  in  adults.  It 
would  appear  that,  although  occasionally  associated  with  albuminous 
urine,  they  also  occur  independently  of  that  condition,  but  are,  in  all  in- 
stances, of  the  gravest  prognostic  import. 

Liebermeister  distinguishes  four  different  degrees  of  febrile  disturb- 
ance of  the  nervous  system,  which  occur  successively  in  severe  cases.  In 
the  first  degree  there  is  general  malaise,  restlessness,  headache,  and  dis- 


166  THE  CONTINUED  FEVERS. 

turbed  sleep.  These  symptoms  correspond  to  the  first  half  of  the  first 
week.  They  are  not  associated  with  disturbance  of  the  intellect,  and  can- 
not be  distinguished  from  the  symptoms  of  the  prodromic  period,  which 
are  due  to  the  action  of  the  poison  upon  the  nervous  system,  without  in- 
crease of  temperature.  In  the  second  degree  the  patient  is  apathetic, 
dull,  his  memory  is  blunted.  There  is  temporary  disturbance  of  the  in- 
tellect, amounting  to  transient  delirium.  These  symptoms  correspond  to 
the  second  half  of  the  first  week  and  the  beginning  of  the  second.  In  the 
tliird  degree  there  is  marked  somnolence,  from  which  the  patient,  how- 
ever, can  be  temporarily  aroused.  This  alternates  with  delirium,  some- 
times muttering,  sometimes  violent  and  associated  with  restlessness  and 
excitement.  This  group  of  systems  begins,  in  severe  cases  unmodified  by 
treatment,  some  time  in  the  second  week,  and  continues  into  the  fourth. 
In  the  fourth  degree  of  the  disturbance  of  the  nervous  system  there  is 
loss  of  consciousness,  out  of  which  the  patients  can  no  longer  be  aroused. 
This  degree  is  gradually  developed  from  the  third  degree,  and  commonly 
begins  some  time  in  the  third  or  fourth  week.  With  the  defervescence, 
the  mental  condition  slowly  improves;  it  is  long,  however,  before  the  pa- 
tient regains  his  old  sharpness  of  memory  and  ability  for  continued  men- 
tal effort. 

Tlie  organs  of  sjyecial  setise  present  certain  symptoms  whicii  are  suffi- 
ciently common  to  have  a  certain  amount  of  diagnostic  value  in  obscure 
cases.  Thus,  epistaxis  is  common.  It  may  occur  at  any  period  of  the  dis- 
ease, but  is  apt  to  occur  early  in  its  course.  It  is  often  slight,  not  ex- 
ceeding a  few  drops,  and  is  for  this  reason  frequently  overlooked.  To 
this  fact  is  doubtless  to  be  ascribed  the  varying  statements  of  the  books 
as  to  its  frequency.  I  am  satisfied  that  slight  epistaxis  occurs  in  a  con- 
siderable proportion  of  the  cases  of  enteric  fever  in  Philadelphia,  at  some 
period  of  the  course  of  the  disease,  and  often  repeatedly.  The  quantity 
of  blood  lost  is  seldom  great;  yet  Murchison  states  that  it  may  amount  to 
several  pounds,  or  even  be  so  profuse  as  to  occasion  death.  If  epistaxis  be 
considerable,  it  is  sometimes  followed  by  a  transient  fall  of  temperature; 
but,  with  this  exception,  it  is  never  followed  by  any  relief  to  the  general 
symptoms  or  to  those  of  the  nervous  system.  Da  Costa  states  that  epis- 
taxis is  not  often  absent  in  grave  cases. 

Suhiectwe  auditory  seyisations,  ringing  and  humming,  often  annoy  pa- 
tients during  the  early  days  of  the  disease.  They  are  said  to  be  most 
marked,  and  to  last  longest,  in  the  cases  that  are  most  severe. 

Deafness  is  very  common.  It  usually  affects  both  ears,  but  may  be 
confined  to  one.  It  is  sometimes  very  marked.  It  commonly  appears 
toward  the  end  of  the  second  week,  and,  in  most  instances,  is  in  part  due 
to  catarrhal  processes  implicating-  the  Eustachian  passage,  and  in  part  to 
the  blunted  sense-perceptions  incident  to  the  action  of  the  poison.  One- 
sided deafness  has  been  ascribed  to  local  inflammation  of  the  ear.     Deaf- 


ENTEKIC    OR   TYPHOID    FEVER.  167 

ness  of  both  ears  was  at  one  time  looked  upon  as  a  favorable  symptom, 
but  the  closer  investigations  of  more  recent  observers  show  that  this  opin- 
ion is  no  longer  tenable.  Among  the  symptoms  connected  with  the  or- 
gans of  special  sense,  the  condition  of  the  pupil  demands  attention.  In  a 
large  proportion  of  the  cases  the  pupils  are  abnormally  dilated  at  some 
period  of  the  disease.  Murchison  found  the  pupils  dilated  in  at  least 
three-fourths  of  his  cases.  This  symptom  commonly  coexists  with  delirium, 
and  comes  on,  like  delirium,  upon  the  cessation  of  the  headache.  It  may, 
however,  be  present  after  the  middle  of  the  second  week,  in  cases  where  de- 
lirium is  absent.  In  respect  to  the  condition  of  the  pupils,  most  cases  of 
enteric  fever  are  in  strong  contrast  with  typhus,  in  which  the  pupils  are, 
for  the  most  part,  contracted.  But,  in  certain  grave  cases  of  the  former 
fever,  after  great  stupor  or  unconsciousness  has  occurred,  the  pupils  are 
contracted,  and  may  be  as  small  as  they  are  in  typhus. 

Conjanctival  injection  is  very  rare  in  enteric  fever,  which  differs  in 
this  respect  from  typhus  and  relapsing  fever.  If  present  at  all,  it  ap- 
pears later  than  in  typhus,  and  is  usually  much  less  intense.  It  was  noted 
by  Murchison  in  8  out  of  100  cases,  by  Louis  in  38  out  of  60,  and  only  three 
times  in  13  cases  observed  by  Jenner.     It  is  not  a  symptom  of  importance. 

Cutaneous  hypercesthesia  was  observed  by  Murchison  in  about  five  per 
cent,  of  the  cases  under  his  care.  It  is  most  common  in  children  and 
females,  and  appears  both  during  the  course  of  the  disease  and  in  the 
convalescence.  It  is  usually  restricted  to  the  abdomen  and  lower  extrem- 
ities, and  is  commonly  associated  with  symptoms  of  spinal  origin,  such  as 
rhachialgia,  tenderness  over  the  spinous  processes  of  the  cervical  and 
dorsal  vertebrae,  and  the  like.  The  tenderness  of  the  abdomen  due  to 
this  cause  is  sometimes  exquisite,  and  is  to  be  carefully  distinguished 
from  that  of  peritonitis. 

Cutaneous  and  muscular  aiiwsthesla,  with  numbness  of  the  extremities, 
also  occur  in  rare  instances. 

This  group  of  symptoms  is  more  common  in  severe  epidemics  than  in 
the  sporadic  forms  of  the  disease,  and  is  to  be  regarded  with  apprehen- 
sion. Murchison,  however,  states  that  hypertesthesia  alone  is  not  a  for- 
midable symptom. 

THE    SKIN. 

TTie  eruption  of  enteric  fever  appears,  as  a  rule,  between  the  seventh 
and  twelfth  days.  Exceptionally  it  is  met  with  as  early  as  the  fourth,  or 
not  discovered  until  as  late  as  the  fourteenth  day.  In  children  it  appears 
a  little  earlier  than  in  adults.  It  is  not  invariably  present.  Out  of  5,988 
cases  admitted  into  the  London  Fever  Hospital  dur;ng  twenty-three  years, 
it  was  noted  in  4,606,  or  in  76.92  per  cent.  Dr.  Murchison's  suggestion 
that,  in  some  of  the  remaining  1,382  cases,  the  fact  of  the  spots  not  being 


168  THE  CONTINUED  FEVERS. 

observed  was  perhaps  due  to  their  not  having  been  looked  for  with  suffi- 
cient care,  is  probably  correct.  The  same  observer  states  that  the  spots 
are  more  frequently  absent  in  patients  under  ten  and  over  thirty  years 
of  age,  than  between  ten  and  thirty,  and  illustrates  his  remark  by  the  fol- 
lowing statistics:  of  1,413  cases  between  ten  and  thirty,  the  eruption  was 
absent  in  143,  or  10  per  cent. ;  of  253  patients  over  thirty,  it  was  noted  as 
absent  in  40,  or  nearly  16  per  cent.;  out  of  107  cases  under  ten,  it  was  not 
noted  in  37,  or  34.5  per  cent.  From  the  same  series  of  statistics  we 
learn  that  no  eruption  was  discovered  in  127  of  905  males,  and  in  97  of 
910  females. 

There  is  no  relation  between  the  abundance  of  the  eruption  and  the 
severity  of  the  symptoms. 

The  typhoid  eruption  is  characteristic  of  the  disease,  and,  when  found, 
clearly  establishes  the  diagnosis.  It  consists  of  small,  slightly  elevated, 
rounded  or  oval,  isolated  spots  of  a  rose-pink  color.  They  are  from  half 
a  line  to  two  lines  in  diameter,  indistinctly  marginate,  and  alike  to  the 
eye  and  the  touch,  faintly  rounded  and  convex,  but  not  acuminate, 
although  some  observers  state  that  a  minute  vesicle  may  in  rare  cases  be 
discovered  at  their  centre.  They  are  frequently  compared  to  flea-bites, 
from  which,  however,  they  differ  in  the  absence  of  the  central  mark  and 
in  their  paler  color.  They  disappear  wholly  on  strong  pressure,  and  return 
immediately  when  the  pressure  is  removed.  They  may  be  made  to  dis- 
appear and  reappear  under  the  eye  by  placing  a  finger  upon  each  side  of 
the  spot  and  making  traction  :  as  the  skin  becomes  tense  they  disappear  ; 
when  it  is  relaxed  they  return.  They  are  developed  in  successive  crops, 
each  spot  lasting  three  or  four  days,  and,  as  it  fades,  being  replaced  by 
a  new  one  at  no  great  distance,  which  runs  the  same  course,  fading  in  its 
turn,  and  so  on,  till  about  the  middle  of  the  third  week.  They  are  not 
found  during  convalescence,  but  reappear,  along  with  the  other  character- 
istic symptoms  of  the  disease,  in  true  relapses.  They  are  never  present 
on  the  dead  body. 

Their  most  common  situation  is  the  abdomen  and  the  lower  part  of  the 
chest,  anteriorly.  They  are  occasionally  present  upon  the  upper  part  of 
the  thigh,  and  are  sometimes  to  be  met  with  between  the  scapulas.  In 
some  instances,  they  are  present  upon  the  back  alone,  and  in  doubtful 
cases  should  be  sought  for  in  this  situation.  They  have  been  met  with,  in 
very  rare  instances,  upon  the  arms  and  legs,  and  Murchison  mentions  a 
single  case  in  which  they  were  found  upon  the  face.  The  duration  of  the 
eruption,  in  cases  that  are  not  unduly  protracted,  is  eight  or  ten  days. 
The  spots  are  usually  few  in  number,  and  discrete  ;  hence,  they  may  be 
readily  overlooked.  It  often  happens  that  not  more  than  six  or  eight  can 
be  discovered,  and  in  most  cases  the  number  present  at  one  time  does 
not  much  exceed  a  score.  They  are,  however,  sometimes  very  numerous, 
but  are  never  confluent  as  in  typhus. 


ENTERIC  OR  TYPHOID  FEVER. 


109 


Each  spot  runs  its  course  without  change,  and  usually  disappears, 
leaving  no  trace  upon  the  skin  ;  although  in  some  instances  a  faint  pig- 
mentation, which  does  not  disappear  upon  pressure,  persists. 

Tabular  arrangement  of  the  chief  points  of  distinction  between  the 
eruption  of  enteric  fever  and  that  of  typhus: 


Enteric  Fever. 

The  spots  are  pink  or  rose-colored  uutil 
they  i'ade,  leaving  no  trace. 
Undergo  little  or  no  change. 

The  spots  are  neither  converted  into 
petechijB,  nor  do  petechiic  appear  inter- 
spersed with  them. 

Circular  or  slightly  oval  in  outline. 

Usually  restricted  to  the  abdomen,  tho- 
rax, and  upper  part  of  the  thighs,  and  the 
interscapular  space. 

Few  in  number  and  discrete. 
Elevated  throughout. 

Momentarily  disappearing  on  pressure. 

Rarely  appear  before  the  seventh  day. 
Appear  in  successive  crops. 


Each  crop  lasts  three  or  four  days,  and 
fades  as  others  appear. 

No  subcutaneous  marbling  or  mottling. 

The  abundance  of  the  eruption  not  at  all 
proportionate  to  the  general  gravity  of  the 
case. 

Not  seen  after  death. 


Typhus. 

The  spots  are  pink  or  dirty  pink  at  first, 
subsiding  into  reddish  brown  stains. 

Become  darker,  and  often  show  a  minute 
extravasation  of  blood  at  the  centre. 

Petechite  very  often  appear. 


Less  regular  in  outline. 

Commonly  distributed  over  the  greater 
part  of  the  body  and  extremities,  with  the 
exception  of  the  neck,  face,  head,  and  pal- 
mar and  plantar  surfaces. 

Copious  and  confluent. 

Raised  at  first,  but  persisting  as  stains 
after  the  elevation  disappears. 

Disappearing  upon  pressure  only  during 
the  first  day  or  two. 

Commonly  on  the  fourth  or  fifth  day. 

Appear  at  once,  and  arise  in  successive 
crops,  although  their  efllorescence  may 
occupy  several  hour.s,  or  a  day  or  two. 

Mo.st  of  the  spots  last  until  the  defer- 
vescence. 

Skin  often  indistinctly  marbled  or  mot- 
tled between  the  spots. 

In  many  instances  the  severity  of  the 
general  symptoms  is  in  direct  ratio  to  the 
copiousness  of  the  eruption  and  the  dark- 
ness of  its  color. 

Often  geen  after  death. 


The  eruption  is  occasionally  preceded  by  a  faint  scarlet  rash  seen  in 
patients  whose  skin  is  fair  and  delicate.  This  rash  is  not  very  common; 
it  is  not  peculiar  to  enteric  fever;  but  it  is  met  with  in  other  diseases  at- 
tended by  pyrexia.  If  well-marked,  and  particularly  if  it  be  associated 
with  slight  sore  throat,  as  has  sometimes  happened,  the  disease  may  be  mis- 
taken for  scarlet  fever. 

True  petechite  are  rare. 

Sudamina  appear  at  a  later  period  in  the  disease.  They  consist  of 
minute,  transparent  vesicles,  scattered  plentifully  over  the  body,  and  are 


170  TIIK    CONTINUED    FEVERS. 

often,  but  not  invariably,  attended  with  profuse  sweatiiifj-.  They  are 
very  common  in  typhoid  fever,  but  are  without  specific  character,  and 
occur  with  perhaps  equal  frequency  in  other  febrile  affections. 

Slight  desquamation  occasionally  occurs  during  convalescence;  the 
hair  falls  out;  and  changes  occur  in  the  nails  indicating  the  arrest  of  nu- 
trition which  has  attended  the  course  of  the  attack. 

Emaciation  is  usually  great;  often  extreme. 

llie  jihysiognomy  of  persons  ill  of  t^'phoid  fever  is  peculiar,  though 
less  characteristic  than  that  of  typhus.  Some  patients,  especially  if  the 
attack  be  mild,  show  but  little  alteration  of  expression  during  its  whole 
course.  Much  more  commonly  the  expression  is  dull,  weary;  the  face 
pale,  with  circumscribed  flushing  over  one  or  both  cheek-bones.  This 
comes  and  goes,  and  is  sometimes  called  forth  or  intensified  by  the  admin- 
istration of  food  or  stimulants.  The  dilatation  of  the  pupils  adds  to  the 
peculiarity  of  the  expression;  and,  in  the  later  stages  of  the  attack,  the 
wasted  tissues,  the  sunken  eyes,  the  circumscribed  flushing  and  hurried 
breathing,  suggest  the  appearance  of  patients  in  advanced  pulmonary 
phthisis. 

SYMPTOMS   KEFERABLE   TO   THE   DIGESm^E   TRACT. 

T7ie  tonr/ue  at  first  has  a  somewhat  swollen  and  flabby  appearance;  it 
is  at  this  period  also  moist  and  covered  with  fur,  commonly  thin  and  whit- 
ish, or  yellowish  white,  sometimes  thick  and  creamy  or  pasty.  Its  edges 
and  tip  are  unusually  red.  It  may  remain  moist  and  furred  during  the 
whole  course  of  the  attack,  or,  during  the  second  week,  the  coating  may 
break  up  into  flaky  patches  of  a  whitish  color,  while  the  surface  of  the 
tongue  remains  bright  red.  This  redness  is  in  peculiar  contrast  to  the 
pallor  of  the  lips  in  the  advanced  stages  of  the  disease,  and  has  given  rise 
to  the  name  of  "  red-tongue  fever,"  by  which  enteric  fever  is  known  in 
some  sections  of  the  West.  It  is  more  common,  after  the  middle  of 
the  second  week,  to  find  the  tongue  dry,  red,  glazed,  and  slightly  or  even 
deeply  fissured,  or  it  is  dry,  with  a  brownish  streak  along  the  middle,  or  a 
triangular  brownish  patch  at  the  tip.  In  cases  in  which  the  typhoid  state 
is  well-developed,  the  tongue  is  usually  covered  with  a  more  or  less  tliick, 
brownish  crust. 

It  is  rare  to  find  the  tongue  firmly  retracted  into  a  globular  mass,  as 
is  sometimes  seen  in  typhus,  and  inability  to  protrude  it  is  less  common 
than  in  that  disease. 

The  lips  often  crack  and  bleed,  and  in  children,  by  reason  of  picking, 
they  frequently  become  very  sore  and  painful.  In  gravi  cases  sordes 
collect  upon  the  teeth.  Hemorrhage  from  the  gums  is  a  rare  occurrence 
in  enteric  fever. 

In  the  first  week  there  is  usually  slight  catarrhal  inflammation  of  the 
faucial  mucous  membrane,  with  enlargement  of  the  tonsils.      The  accumu 


ENTERIC    OK    TYPHOID    FEVEK.  171 

lation  of  the  altered  secretion  in  the  naso-pliaryngeal  space  occasions  in 
some  patients  considerable  discomfort.  Later  the  throat  becomes  dry, 
and  there  is,  as  a  result,  more  or  less  difficulty  in  swallowing. 

Tlie  appetite  is,  as  a  rule,  greatly  impaired ;  it  is  wholly  lost  when  the 
tongue  becomes  dry.  In  mild  cases,  when  the  tongue  retains  its  moist- 
ure, some  appetite  may  be  present  throughout  the  attack.  I  have  seen  a 
case  in  which,  with  a  very  red  but  moist  tongue,  evenly  coated  at  first, 
but  later  showing  only  flaky  patches  of  whitish  fur,  the  appetite  was  good 
during  the  whole  course  of  the  disease.  In  this  patient,  a  lad  aged  nine- 
teen, the  highest  evening  temperature  was  40°  C.  (104  °  F.),  The  secre- 
tion of  saliva  is  in  most  cases  greatly  impaired,  and  there  is  good  ground 
for  believing  that  a  like  impairment  of  the  secretion  of  the  pancreatic 
juice  takes  place.  For  this  reason  starchy  articles  of  food  are  not  so  well 
digested  as  albuminous  foods;  and  it  is  probable  that,  while  small  amounts 
of  arrow-root  or  gruel  may  be  advantageous  in  certain  cases,  because  they 
augment  the  food-volume,  in  the  majority  of  instances  any  considerable 
quantity  of  starch  is  injurious  and  likely  to  add  to  the  intestinal  irri- 
tation. 

Thirst  is  commonly  present  in  the  early  stages;  in  many  instances  it 
is  urgent. 

Nausea  and  vomiting  occur  in  the  early  stages  of  a  small  proportion  of 
the  cases.  These  are  sometimes  among  the  earlier  symptoms,  and  being 
associated  with  headache  and  general  malaise,  lead  the  patient  to  suppose 
that  he  is  suffering  from  "  biliousness."  More  frequently  these  symptoms 
appear  during  the  second  week.  The  vomiting  in  most  cases  is  only  oc- 
casional; it  is  sometimes  persistent  and  distressing.  In  the  latter  case 
it  is  apt  to  be  associated  with  epigastric  soreness  and  pain.  Some  ob- 
servers look  upon  vomiting  at  the  beginning  of  the  attack  as  a  favorable 
symptom;  by  others  it  is  regarded  in  the  opposite  light.  There  are  no 
statistics  by  which  to  settle  this  question,  but  so  far  as  my  own  obser- 
vation goes,  early  vomiting,  which  is  not  common  in  enteric  fever  as  it 
occurs  in  Philadelphia,  has  been  followed  by  the  severest  forms  of  the 
disease.  Vomiting  after  the  end  of  the  second  week, is  of  grave  import; 
it  is  often  the  first  sign  of  peritonitis.  The  matters  vomited  usually  con- 
sist of  food,  sometimes  in  a  partially  digested  state,  or  they  consist  sim- 
ply of  gastric  mucus  stained  green  with  bile. 

Abdominal  tenderness  and  pain  are  present  in  the  majority  of  the 
cases.  They  are  not,  however,  necessary  symptoms,  and  are  sometimes 
absent  throughout  tlie  attack.  Palpation  is  to  be  made  with  circumspec- 
tion in  the  later  periods  of  the  attack,  lest  mechanical  violence  give  rise 
to  peritonitis,  or  even  perforation  of  the  ilium  at  a  point  of  deep  ulcera- 
tion.    Bartholow  '  mentions  a  case  in  which  fatal  peritonitis,  due  to  rup- 

'  Practice  of  Medicine,  1880. 


172  .  THE    CONTINUED    FEVERS. 

ture  of  the  spleen,  was  caused  during  convalescence  by  a  not  violent 
blow.  The  tenderness  is  elicited  by  light  pressure  in  the  right  iliac  fossa, 
but  it  is  not  necessarily  limited  to  that  region.  In  many  cases  it  is  also 
experienced  in  the  umbilical  region  and  even  in  the  left  side  of  the  abdo- 
men. Spontaneous  pain  is  also  often  complained  of.  Pain  and  tender- 
ness in  the  abdomen  are  largely,  if  not  wholly,  due  to  local  morbid  pro- 
cesses, and  are  to  be  looked  upon  as  to  some  extent  the  measure  of  the 
extent  and  intensity  of  the  intestinal  lesions.  This  statement  must,  how- 
ever, be  qualified  by  adding  that  a  most  serious,  or  even  fatal  lesion  of 
the  gut  may  sometimes  occur  without  previous  marked  pain  or  tenderness. 

Meteorism  is  present  in  most  cases  ;  according  to  Sir  William  Jenner  ' 
it  is  observed  to  some  extent  in  all  cases.  Murchison  states,  on  the  other 
hand,  that  out  of  100  cases  he  found  meteorism  in  79,  and  that  the  abdo- 
men remained  flat  throughout  in  21  ;  and  Louis  noted  meteorism  in  only 
89  out  of  134  cases.  The  amount  of  distention  varies  from  slight  fulness 
to  a  tympany  so  great  as  to  interfere  with  the  contraction  of  the  dia- 
phragm and  impede  respiration.  In  this  way  meteorism  increases  the 
danger  of  congestion  of  the  lungs.  It  does  not  usually  appear  until 
after  the  first  week,  and  is  most  developed  in  severe  cases.  Thus,  Murchi- 
son noted  it  in  20  out  of  21  fatal  cases;  Jenner  in  18  out  of  19  fatal 
cases,  and  Louis  in  one-half  of  his  fatal  cases.  Furthermore,  the  first- 
named  of  these  observers  found  that,  out  of  17  cases  in  which  extreme 
tympany  arose,  7  died  ;  while  of  G2  in  which  it  was  moderate  or  slight, 
14  died,  and  of  21  where  it  was  absent,  none  died,  and  Louis  noted  great 
meteorism  in  only  7  cases  among  88  in  which  recovery  took  place.  These 
statistics  are  of  great  interest  as  indicating  the  importance  of  the  intes- 
tinal lesions  in  regard  to  the  prognosis.  Tympany,  like  abdominal  ten- 
derness and  pain,  is  in  part  a  measure  of  the  extent  of  the  mischief 
wrought  in  the  intestines.  It  is  due  to  excessive  development  of  gas  and 
to  deficient  expulsive  power  in  the  bowels.  The  first  of  these  factors  has 
its  pathological  genesis  in  the  impaired  quality  of  the  digestive  fluids,  and 
a  tendency  to  the  rapid  decomposition  of  imperfectly  digested  food;  the 
second  in  general  lowering  of  nerve-tone,  or  in  local  injury  to  the  bowel. 
Jenner  calls  attention  to  the  fact  that  a  single  deep  ulcer  will  paralyze 
the  action  of  the  bowel  and  lead  to  such  an  accumulation  of  flatus  as 
produces  enormous  distention  of  the  abdomen.  Weakness  of  the  abdom- 
inal muscles  contributes  also  to  the  accumulation  of  flatus.  The  condi- 
tions which  underlie  abdominal  distention  in  this  disease  attain  their 
maximum  during  the  latter  half  of  the  third  and  in  the  fourth  period  of 
the  fever,  and  it  is  at  this  time  that  meteorism  may,  in  the  more  severe 
cases,  become  both  a  troublesome  and  an  alarming  symptom. 

The  spleen  is,  as  a  rule,  enlarged. — Augmentation  in  the  bulk  of  this 


'  On  the  Treatment  of  .Typhoid  Fever.     Lancet,  November  15,  1879. 


ENTERIC  OK  TYPHOID  FEVER.  ITS 

organ  is  a  prominent  and  characteristic  symptom  ;  it  occurs  early,  and 
may  often  be  demonstrated  before  the  close  of  the  first  week.  It  in- 
creases during  the  second  week,  and  diminishes  again  during  the  fourth. 
The  amount  of  enlargement  is  usually  considerable  ;  at  the  height  of 
the  disease  the  organ  sometimes  attains  three  times  its  natural  bulk,  or 
more,  and  can  be  felt  through  the  abdominal  wall.  The  enlargement  is 
greatest  in  persons  under  thirty  years  of  age.  In  a  few  cases  it  is  absent 
altogether,  and  this  is  more  common  in  old  than  in  young  persons. 

Diarrhoea  is  one  of  the  most  common  symptoms  in  enteric  fever. 
Although  cases  occur  in  which  this  symptom  is  absent  throughout  the 
whole  course  of  the  attack,  they  are  to  be  looked  upon  as  exceptional. 
Out  of  100  cases  in  which  diarrhoea  was  made  the  subject  of  special  obser- 
vation by  Murchison,  it  occurred  in  93.  The  time  at  which  the  diarrhcea 
first  appears  is  very  variable.  It  is  sometimes  present  in  the  prodromic 
period,  or  if  not  present  at  this  time,  it  is  often  induced  by  purgatives 
taken  by  the  patient  under  the  impression  that  he  is  suffering  from  a 
bilious  attack.  Diarrhcea  sometimes  appears  early  in  the  course  of  the 
disease,  but  ceases  after  a  few  days,  and  does  not  return.  More  com- 
monly it  is  a  prominent  symptom  during  the  whole  course  of  the  illness. 
It  sometimes  happens  that  diarrhoea  is  absent  until  the  third  or  fourth 
week  of  the  disease,  and  is  then  profuse.  The  movements  are  not  often 
attended  with  pain,  and  never  by  tenesmus.  Their  frequency  varies. 
In  the  greater  number  of  cases  they  do  not  exceed  three  or  four  a  day  ; 
not  infrequently,  on  the  other  hand,  they  may  amount  to  twelve  or  fifteen 
in  the  course  of  twenty-four  hours.  There  is  no  constant  relation  be- 
tween the  urgency  of  the  diarrhoea  and  the  extent  of  the  intestinal  lesions. 
Diarrhoea  may  be  altogether  absent  in  cases  in  which,  after  death,  exten- 
sive and  deep  ulceration  is  found.  Profuse  hemorrhage  or  perforation 
sometimes  occurs  in  cases  unattended  by  diarrhoea  or  any  other  previous 
abdominal  symptom.  Prolonged  constipation  is  attended  with  the  dan- 
ger of  the  formation  of  firm  scybala  which  are  liable  to  do  harm  by  in- 
creasing the  extent  and  depth  of  the  ulceration,  or  by  directly  leading  to 
perforation. 

When  diarrhcea  occurs  during  the  first  week,  the  stools  are  thin  and 
brownish  ;  but  toward  the  end  of  the  second  week  they  assume  the  ap- 
pearance peculiar  to  the  disease.  They  are  then  liquid  and  of  an  ochrous 
color.  On  standing,  the  stool  separates  into  two  layers  ;  a  supernatant 
fluid  and  a  flaky  sediment.  The  former  has  a  yellowish  or  pale  brown 
color  ;  its  specific  gravity  is  1015,  and  it  contains  about  40  parts  in 
1,000  of  solid  matter,  which  consists  chiefly  of  albumen  and  soluble  salts, 
particularly  chloride  of  sodium.  The  deposit  is  made  up  of  particles  of 
undigested  food,  disintegrating  intestinal  epithelium  and  blood-corpuscles, 
shreds  of  sloughs,  which  are  separated  from  the  intestinal  ulcers,  and 
multitudes  of  crystals  of  triple  phosphate  (Murchison).     The  reaction  of 


174  THK  CONTINUED  FEVEKS. 

« 

the  typhoid  stools  is  alkaline.  Sometimes,  ii)stead  of  being  watery,  they 
are  frothy  or  pultaceous,  or  they  may  be  mixed  with  blood. 

Gurgllnc)  in  the  right  iliac  fossa  is  often  elicited  upon  palpation. 
Associated  with  tenderness,  this  symptom  undoubtedly  has  diagnostic 
value;  but  it  occurs  so  constantly  in  other  affections,  attended  by  diar- 
rhoea, that  it  cannot  be  looked  upon  as  a  characteristic  phenomenon  of  en- 
teric fever. 

Hemorrhage  from  the  bowels  is  of  frequent  occurrence  and  constitutes 
a  s3nnptom  of  the  gravest  importance.  Sometimes  it  amounts  merely  to 
a  few  streaks  of  blood,  or  a  little  bloody  mucus  ;  in  others  it  is  more 
abundant;  or  it  may  be  even  copious,  amounting  to  one  or  more  quarts. 
The  color  of  the  blood  is  oftei)  bright  red,  particularly  if  it  be  promptly 
discharged  ;  it  may  be  of  a  syrupy  consistence,  or  loosely  clotted.  If  it 
be  retained  for  some  time  in  the  intestine  (concealed  hemorrhage),  it  be- 
comes tarry  in  consistence,  and  of  an  olive-green  or  brown  color.  Mur- 
chison  states  that  hemorrhage,  amounting  to  over  six  ounces,  occurred  in 
58  of  1,564  cases  under  his  observation,  or  in  3.77  per  cent.  It  occurred 
in  8  of  134  cases  noted  by  Louis,  or  in  5.9  per  cent.  In  this  estimate  the 
milder  cases  appear  not  to  have  been  included.  Liebermeister  found  that 
hemorrhage  from  the  bowels  occurred  among  the  cases  treated  in  the  hos- 
pital at  Basle  in  127  of  1,743  patients,  or  in  7.3  per  cent.  The  proportion 
among  men  was  5  per  cent,  of  all  cases  ;  that  among  women,  10.  In 
this  series  of  cases,  the  lighter  hemorrhages  are  included,  those  only  being 
thrown  out  in  which  a  mere  trace  of  blood  was  discovered.  Griesinger 
observed  32  cases  of  hemorrhage  in  600  patients,  or  5.3  per  cent. 

It  is  somewhat  less  frequent  in  children  than  in  adults. 

The  date  of  the  appearance  of  the  hemorrhage  shows,  according  to  the 
statistics  of  different  observers,  considerable  variation.  Liebermeister 
found  that  in  81  cases  of  intestinal  hemorrhage  in  which  the  chronology 
was  carefully  kept,  7  took  place  during  the  first  week  ;  33  during  the 
second  ;  19  during  the  third;  14  during  the  fourth;  and  8  at  a  later 
period.  Griesinger,  in  32  cases  of  hemorrhage,  found  no  instance  in  which 
this  accident  occurred  during  the  first  week  ;  during  the  second,  and 
chiefly  toward  the  end  of  it,  there  were  10  cases  ;  during  the  third  week, 
8;  during  the  fourth,  8;  in  the  fifth,  2;  in  the  sixth,  3.  Of  60  cases  ob- 
served by  Murchison,  the  bleeding  commenced  during  the  second  week, 
mostly  toward  its  close,  in  8;  during  the  third  week  in  28;  during  the 
fourth  in  17;  during  the  fifth  in  1;  during  the  sixth  in  3;  during  the 
seventh  in  1,  and  during  the  eighth  in  1;  while  in  one  case  the  date  of  its 
occurrence  was  not  noted.  In  three  of  Murchison's  cases,  where  it  took 
place  on  the  sixteenth,  eighteenth,  and  nineteenth  daj's,  it  recurred  respec- 
tively on  the  forty-ninth,  thirty-third,  and  forty-fourth  days.  The  last 
named  author  states  that  he  has  known  slight  intestinal  hemorrhage  to 
take  place  as  early  as  the  fifth  or  sixth  day,  and  even  copious  hemorrhage 


ENTERIC    OR    TYPHOID    FEVER.  175 

at  a  period  so  early  in  the  disease  as  to  preclude,  in  all  probability,  the 
■existence  of  intestinal  ulceration. 

The  source  of  the  hemorrhage  varies  with  the  period  of  its  occurrence. 
During  the  early  period  of  the  disease,  prior  to  the  latter  part  of  the  sec- 
ond week,  the  hemorrhages  arise  from  the  rupture  of  minute  vessels 
within  the  relaxed  and  highly  vascular  tissues  of  the  infiltrated  patches; 
in  the  third  and  fourth  weeks,  they  are  due  to  the  separation  of  sloughs; 
and  at  this  period,  or  later,  to  the  destructive  action  of  progressive  ulcera- 
tion. Hemorrhage  from  the  bowels  is  occasionally  associated  with  nose- 
bleeding,  the  spitting  or  vomiting  of  blood,  or  with  hsematuria,  and  with 
petechise,  as  evidences  of  profound  alteration  of  the  state  of  the  blood,  in 
consequence  of  the  action  of  the  typhoid  poison;  or  hemorrhages  from 
various  mucous  tracts  may  occur  during  the  course  of  the  disease,  as  evi- 
dences of  the  existence  of  the  hemorrhagic  diathesis. 

Extensive  hemorrhage  may  take  place  into  the  bowel,  and  death  en- 
sue in  consequence,  without  the  escape  of  the  blood  externally.  If  a 
large  amount  of  blood  escape  into  the  intestine,  whether  it  be  voided  ex- 
ternally or  not,  symptoms  of  collapse  speedily  ensue.  The  patient  sud- 
denly becomes  extremely  prostrate;  his  face  grows  pale;  his  pulse  weak 
and  frequent;  his  extremities  cold;  while  the  temperature  falls,  with  great 
abruptness,  several  degrees.  If  the  blood  be  not  discharged,  an  area  of 
the  abdomen,  previously  tj^mpanitic,  becomes  dull.  The  temperature 
sometimes  falls  to  a  point  below  the  normal.  This  fall  is  followed  by  the 
same  general  amelioration  in  the  condition  of  the  patient  that  results  from 
a  decided  remission  of  fever  under  other  circumstances;  in  particular,  by 
the  diminution  or  disappearance  of  serious  nervous  symptoms  due  to  the 
prolonged  high  temperature.  The  change  is,  however,  usually  transitory; 
within  twenty-four  hours  the  temperature  rapidly  regains  its  former 
height,  or  rises  beyond  it,  and  the  disease  resumes  its  course. 

It  is  to  this  transient  amelioration  of  the  general  symptoms  of  the  dis- 
ease that  is  doubtless  due  the  opinion  entertained  by  some  observers  that 
the  occurrence  of  hemorrhage  is  productive  of  benefit  to  the  patient. 
Among  those  who  hold  this  view  are  Graves  and  Trousseau.  The  great  ma- 
jority of  observers,  however,  concur  in  the  opinion  that  it  is  a  dangerous 
symptom.  Of  Murchison's  60  cases,  32,  or  53.3  per  cent.,  terminated  fa- 
tally; in  11  of  these  the  immediate  cause  of  death  was  peritonitis;  of  the 
remaining  21  cases,  14  died  within  three  days  of  the  bleeding;  and  of  these 
14  cases,  8  within  a  few  hours.  Of  Liebermeister's  127  cases  in  which 
liemorrhage  occurred,  49,  or  38. G  per  cent.,  died.  Of  Griesinger's  32 
cases,  10,  or  31.2  per  cent.,  died,  7  of  them  within  four  days. 

Most  of  the  cases  in  which  copious  intestinal  hemorrhage  occurs,  have 
been  previously  severe,  and  attended  by  considerable  diarrhoea;  in  a  small 
proportion  of  them,  however,  the  previous  symptoms  have  been  mild;  and 
in  a  few  of  them,  diarrhcea  has  been  absent.     It  would  appear  then  that 


176  THE  CONTINUED  FEVERS. 

hemorrhage  occ-urs  most  frequently  in  the  severer  cases  of  the  disease, 
where  the  mortality  would  be  high  without  the  occurrence  of  this  acci- 
dent. Furthermore,  the  fall  of  temperature  attendant  upon  hemorrhage 
and  the  consequent  amelioration  of  the  general  symptoms  of  the  disease, 
if  they  occur  in  the  later  periods  of  the  fever,  may  usher  in  a  permanent 
improvement.  It  is  probable,  therefore,  that  intestinal  hemorrhage,  al- 
though unquestionably  influencing  the  prognosis  unfavorably,  is  less  dan- 
gerous than  some  observers  have  been  led  to  suppose.  A  slight  hemor- 
rhage probably  affects  the  result  but  slightly,  if  at  all;  even  in  a  grave 
case,  it  is  of  little  importance,  except  in  so  far  as  it  excites  the  fear  of  a 
profuse  recurrence.  Copious  hemorrhages  at  any  period  of  the  disease 
are  to  be  regarded  with  apprehension,  because  of  the  increased  debility 
arising  from  the  actual  loss  of  blood.  If  they  occur  early,  they  render 
the  patient  less  able  to  bear  the  prolonged  fever;  if  late,  death  may  ensue 
from  collapse. 

It  has  been  thought  that  the  danger  of  intestinal  hemorrhage  is  in- 
creased by  the  treatment  by  means  of  cold  baths.  And  it  would  appear 
that  the  application  of  cold  to  the  entire  surface  of  the  body,  by  inducing 
contraction  of  the  superficial  blood-vessels,  must  drive  the  blood  to  the 
internal  organs,  and  thus  favor  hemorrhage.  Liebermeister,  however, 
found  that  of  8G1  cases  treated  before  the  introduction  of  the  cold  bath- 
ing, 72,  or  8.4  per  cent.,  had  intestinal  hemorrhage;  but  that  of  882  cases 
treated  after  the  introduction  of  the  cold  baths,  hemorrhage  occurred  in 
55,  or  G.2  per  cent.  He  concludes,  therefore,  that  "  the  frequency  of  intes- 
tinal hemorrhage  has  materially  diminished  under  the  cold-water  treat- 
ment."    This  point  cannot  at  present  be  looked  upon  as  settled. 

SYMPTOMS  BEPERABLE  TO  THE  ORGANS  OF  RESPIRATION. 

The  frequency  of  respiration  varies  with  the  intensity  of  the  febrile 
movement,  in  the  absence  of  pulmonary  complications.  It  rises  with  the 
pulse;  but  in  cases  characterized  by  an  unusually  slow  pulse,  there  is  no 
corresponding  slowness  of  the  breathing.  At  times  the  respiration  is 
shallow,  noisy,  or  irregular,  but  these  symptoms  arise  for  the  most  part  in 
the  gravest  cases. 

A  certain  amount  of  bronchial  catarrh  is  so  frequent  in  enteric  fever 
that  it  merits  consideration  as  a  symptom  of  the  disease  rather  than  as  a 
complication.  In  a  majority  of  the  cases  this  does  not  manifest  itself  by 
cough;  and  the  cough,  when  present,  is  often  by  no  means  proportionate 
to  the  intensity  of  the  bronchial  congestion.  Upon  auscultation  we  de- 
tect rales  which  are  often  loud  and  ringing. 

IIy2)ostasis  gives  rise  to  notable  enfeeblement  of  the  respiratory 
murmur  at  the  most  dependent  portions  of  the  lungs,  and  to  impairment 
of  resonance  upon  percussion. 


ENTERIC  OR  TYPHOID  FEVER.  177 


THE   UEINE. 

The  urine  is  diminished  in  quantity  during  the  first  and  second 
■weeks.  Notwithstanding  the  increased  amount  of  fluid  consumed  by 
the  patient,  the  urine  excreted  may  not  exceed  one-half  or  even  one- 
fourth  the  normal  quantity.  In  most  cases  it  is  diminished  from  the 
commencement  of  the  attack  until  convalescence,  when  it  becomes,  as  a 
general  rule,  copious  and  of  low  specific  gravity.  Sometimes,  however, 
a  considerable  increase  in  quantity  takes  place  about  the  end  of  the  sec- 
ond week.  Its  color  is  at  first  darker  than  in  health,  in  consequence  of 
the  rapid  destruction  of  the  pigmented  tissues  of  the  body,  and  particu-* 
larly  of  the  red  blood  corpuscles.  In  the  advanced  stages  of  the  disease, 
and  during  convalescence,  it  is  pale.  As  a  general  rule  the  urine  is  acid 
throughout  the  disease;  toward  the  end  of  the  attack,  however,  the  acid 
reaction  becomes  less  intense,  and  in  some  instances  the  urine  is  at  this 
time  even  feebly  alkaline.  The  specific  gravity  varies  in  proportion  to 
the  amount.  The  scanty  urine  of  the  early  periods  ranges  from  1020  to 
1030;  after  tlie  close  of  the  second  week,  in  some  instances,  and  almost 
invariably  during  convalescence,  the  specific  gravity  falls  to  a  point  con- 
siderably below  the  normal.  The  abundant  limpid  urine  of  early  conva- 
lescence is  often  as  low  as  1008  or  1005. 

The  daily  excretion  of  urea  is  invariably  increased  at  some  period  of 
the  attack,  and  in  almost  all  instances  throughout  the  whole  course  of  the 
disease.  This  increase  is  greatest  during  the  first,  week;  after  that,  the 
quantity  usually  falls  off  somewhat  until  convalescence,  when  it  may  re- 
main for  several  days  lower  than  normal.  According  to  Parkes,  the 
average  increase  is  about  one-fifth,  but  occasionally  this  amount  is  far 
exceeded.  The  quantity  of  urea  excreted  is  usually  greatest,  when  the 
temperature  is  highest,  and,  as  the  temperature  subsides,  the  urea  dimin- 
ishes to  the  standard  of  health  or  below  it.  The  amount  of  urea  does 
not  appear  to  be  dependent  upon  the  frequency  or  intensity  of  the  diar- 
rhoea. It  would  appear  from  the  observations  of  Dr.  Parkes,  that  the 
urea  may  be  reduced  during  the  occurrence  of  inflammatory  complica- 
tions. In  one  case,  this  observer  ascertained  that  the  amount  of  urea, 
during  an  intercurrent  attack  of  pleurisy,  was  one-third  less  than  the 
average  before  the  occurrence  of  this  complication.  The  uric  acid  is 
always  increased.  During  the  latter  period  of  the  disease  the  amount 
falls  to  the  normal,  and  during  convalescence,  it  is  less  than  in  health. 
Copious  deposits  of  the  urates  may  occur  at  any  time  in  the  course  of  the 
disease.  They  are  not  necessarily  critical,  and  are  therefore  without  prog- 
nostic value.  The  chlorides  are  greatly  diminished.  Sometimes  they  do 
not  exceed  a  mere  trace.  This  diminution  in  the  chlorides  cannot  be 
wholly  explained  either  by  the  diminished  amount  ingested  or  by  the 
increased  amount  voided  with  the  stools.  It  would  appear  that  they  are 
12 


178  THE  CONTINUED  FEVERS. 

temporarily  stored  up  in  the  tissues.  With  the  advent  of  convalescence, 
the  chlorides  are  greatly  increased. 

In  many  cases  the  urine  contains  albumen.  Of  549  cases,  collected 
by  Murchison  from  various  sources,  albumen  was  discovered  in  157,  or 
in  28.6  per  cent.  It  rarely  appears  earlier  than  the  middle  of  the  third 
week;  the  amount  is  small,  and  in  most  cases  the  albuminuria  is  tran- 
sient, disappearing  shortly  after  the  abatement  of  the  fever.  The  ap- 
pearance of  the  albumen  in  the  urine  is  due  to  the  parenchymatous 
degeneration  of  the  kidneys,  and  is  a  direct  consequence  of  prolonged 
high  temperature.  It  coincides  in  the  chronology  of  the  disease  with  the 
appearance  of  cerebral  symptoms  of  gravity  and  the  other  phenomena 
of  the  typhoid  state  (third  degree  of  disturbance  of  the  ners'ous  system — 
Liebermeister).  Acute  parenchymatous  nephritis  occasionally  occurs;  it 
will  be  spoken  of  under  the  head  of  complications. 

Hematuria  is  occasionally  encountered;  it  is  commonly  associated 
with  other  hemorrhages.  Blood-corpuscles  may  be  found,  in  connection 
with  albumen  and  renal  epithelium,  in  the  urine  of  severe  cases.  Tube- 
casts  are  commonly  discovered  along  with  the  albumen;  they  are  also 
occasionally  met  with  where  albumen  is  absent. 

Leucine  and  tyrosine,  creatinine,  and  the  urinary  indigo  are  occasion- 
ally met  with.  In  the  later  stages  of  the  disease,  when  the  urine  is  feebly 
acid  in  reaction,  it  often  contains  large  amounts  of  the  phosphates. 

Complications  and  Sequels. 

Enteric  fever  is  conspicuous  among  the  acute  diseases  for  the  number 
and  variety  of  its  complications  and  sequels.  The  prolonged  high  tem- 
perature, the  serious  impairment  of  nutrition  which  affects  the  tissues  of 
the  body  in  the  most  general  manner,  and  the  enfeeblement  of  the  cir- 
culation characteristic  of  the  developed  disease,  contribute  directly  and 
indirectly  to  the  excessive  development  of  certain  of  the  lesions.  Thus, 
on  the  one  hand,  phenomena  of  the  disease  itself  attain  the  importance  of 
secondary  affections,  while  on  the  other,  the  length  of  time  during  which 
the  powers  of  resistance  to  evil  influences  from  without  are  lowered, 
renders  the  patient  especially  liable  to  the  development  of  intercurrent 
affections,  not  essentially  dependent  upon  the  primary  disease,  but  of  an 
accidental  kind. 

Hence,  the  complications  and  sequels  of  this  disease  fall  of  themselves 
into  two  general  classes.  Of  these,  the  first  comprises  those  which  are 
closely  connected  with  the  pathological  processes  of  the  particular  form  of 
fever,  and  which  are  to  be  regarded  as  due  to  an  unusual  development  of  the 
same,  either  in  extent  or  in  intensity.  Here  are  to  be  considered  those 
complications  which  we  must  look  upon  as  the  accidents  of  the  intestinal 
lesions,  such  as  hemorrhage,  which  is  so  common  that  it  has  already  been 


ENTERIC    OR    TYPHOID    FEVER.  179 

treated  of  as  a  symptom,  perforation,  and  peritonitis,  with  or  Avithout 
perforation.  The  general  lesions,  which  are  of  the  nature  of  a  wide- 
spread impairment  of  nutrition,  leading  to  parenchymatous  degeneration 
of  the  muscular  system,  the  glands,  and  the  tissues  of  the  nervous  system, 
may  be  followed  by  ruptures  of  muscles,  abscesses,  parotitis,  nephritis, 
and  various  affections  of  the  nervous  system;  and  finally,  the  enfeeble- 
ment  of  the  circulation  leads  to  various  venous  congestions,  hypostasis, 
(jedema,  thrombosis,  embolism,  infarction,  and  secondary  pathological 
processes  dependent  upon  these  occurrences.  The  second  group  com- 
prises occurrences  not  necessarily  dependent  upon  the  malady,  but  to 
which  the  condition  of  the  patient  renders  him  peculiarly  liable.  These 
are  mainly  acute  inflammatory  attacks,  such  as  pneumonia  or  pleurisy, 
and  the  development  of  intercurrent  diseases  of  an  infectious  character, 
as  erysipelas  or  diphtheria. 

The  impairment  of  nutrition  characteristic  of  the  developed  disease 
manifests  itself  in  a  peculiar  tendency  on  the  part  of  the  tissues  to  break 
down  under  the  influence  of  slight  causes.  Hence,  trifling  injuries  may 
give  rise  to  serious  destruction  of  tissue.  The  pressure  of  the  teeth,  or 
the  sharp  point  of  a  tooth,  may  cause  an  ulcer  upon  the  tongue  which 
spreads,  becomes  gangrenous,  and  refuses  to  heal  until  the  defervescence. 
In  a  like  manner,  bed-sores  are  not  only  intractable  while  the  fever  lasts, 
but  they  tend  to  become  deep  and  extensive,  despite  the  most  careful  efforts 
to  guard  the  parts  from  pressure.  Venereal  ulcers  tend  to  become  gan- 
grenous, and  sometimes  result  in  the  extensive  destruction  of  parts,  and 
Liebermeister  has  seen  old  fistulous  tracts,  dependent  upon  former  disease 
of  the  bone,  reopen,  and  necrosis  of  the  bone  supervene. 

It  is  a  matter  of  common  observation  that  wounds  do  not  heal  well,  if 
the  patient  develop  enteric  fever. 

Diseases  of  the  respiratory  tract  constitute  an  important  group  of  the 
complications  of  enteric  fever. 

Laryngitis  occasionally  occurs.  It  is  a  serious  complication,  and  is  not 
infrequently  the  cause  of  death.  The  laryngeal  inflammations,  which  occur 
as  complications  of  fevers,  may  be  grouped  under  these  headings:  1,  QEde- 
matous  Laryngitis;  3,  Ulcerative  Laryngitis;  3,  Laryngeal  Perichondritis.' 

"  Practically  it  is  often  exceedingly  difficult  to  separate  these  various 
forms  even  at  the  post-mortem,  so  far  do  they  overlap  each  other.  Qi^de- 
ma  may  exist  alone,  or  it  may  result  from  either  of  the  others;  ulceration 
may  march  steadily  deeper  until  the  cartilages  are  involved;  or  the  peri- 
chondritis may  produce  an  abscess  which  will  burst,  and  so  form  an  ulcer, 
Pow  much  more  difficult,  nay  often  impossible,  then  is  it  to  diagnosti- 
cate precisely  the  form  of  the  disease,  when,  happily,  the  patient  recovers. 
Dyspnoea,  suffocation — this  is  the  one  great  overshadowing  clinical  fact 


'  See  the  Fifth  Toner  Lecture  (On  the  Surgical   Complications  and  Sequels  of  the 
Continued  Fevers),  by  W.  W.  Keen,  M.D.,  Washington,  1877. 


180  THE  CONTINUED  FEVERS. 

which  groups  them  all  together,  whatever  the  form  of  the  disease,  or  of 
the  preceding  fever." — (Keen.) 

This  is  a  rare  complication  in  this  country;  it  is  rare  also  in  England. 
Of  13,000  eases  treated  in  the  London  Fever  Hospital,  Murchison  records 
only  21  of  laryngitis;  8  of  these  proved  fatal.  Laryngitis  occurred  in  but 
3  or  4  cases  of  enteric  fever.  On  the  other  hand,  it  appears  to  be  very 
common  in  Germany.  Griesinger  met  with  laryngeal  ulceration  in  31  out 
of  118,  and  Hoffmann  in  28  out  of  250  cases  examined  after  death.  These 
ulcers  are  sometimes  found  in  the  dead  body,  in  cases  where  there  had 
been  no  symptoms  referable  to  the  larynx  during  life.  They  were  at  one 
time  regarded  as  specific  in  their  character,  and  as  due  to  "  typhoid  "  in- 
filtration of  the  laryngeal  glands.  According  to  Liebermeister  they  are 
due  to  secondary  changes,  resulting  from  circumscribed  "  diphtheritic  " 
infiltration  of  the  mucous  membrane.  Others  do  not  believe  that  they  are 
of  specific  origin,  but  that  they  are  to  be  referred  to  the  depraved  nutri- 
tion of  fever-patients,  in  consequence  of  which  a  low  grade  of  inflamma- 
tion readily  follows  slight  irritation,  and  tends  to  rise  rapidly  into  ulcera- 
tion, and  even  into  local  gangrene.  Dr.  Keen  suggests  that  local  stasis 
of  the  blood,  or  clots  in  the  vessels,  are  not  unimportant  factors  in  the 
production  of  the  laryngeal  lesions.  The  areas  of  ulceration  are  usually 
small;  they  may,  however,  become  extensive,  and  the  ulcers  may  extend 
in  depth,  implicating  the  cartilages.  They  may  be  few  in  number,  or  nu- 
merous and  confluent.  Their  most  common  seat  is  the  posterior  wall  of 
the  larynx,  which  is  most  abundantly  supplied  with  blood-vessels.  Hence, 
they  frequently  involve  the  insertion  of  the  vocal  chords.  They  are  not 
uncommon  in  the  epiglottis,  particularly  at  its  margins.  Hoarseness,  even 
aphonia,  difficulty  in  swallowing,  and  a  troublesome,  tickling  cough  are 
among  the  symptoms  to  which  they  give  rise. 

The  laryngeal  complications  of  the  continued  fevers  are  far  more  rare 
in  children  than  in  adults,  and  somewhat  less  common  in  women  than  in 
men.  Cases  in  which  cough  has  been  prominent  during  the  course  of  the 
attack,  or  where  the  patient  in  his  delirium  has  used  his  voice  exces- 
sively, are  especially  disposed  to  these  troubles.  Laryngitis,  during  con- 
valescence, may  occur  from  various  causes  and  thus  constitute  a  sequel 
of  the  primary  fever. 

Acute  oedema  glottidis  may  arise  in  consequence  of  laryngeal  ulcers 
of  small  extent.  It  is  more  commonly  due  to  erysipelas  or  parotitis,  and 
it  is  thought  by  some  observers  to  occasionally  occur  as  a  simple  oedema 
in  consequence  of  asthenia. 

Perichondritis  may  occur  without  previous  ulceration,  as  is  shown  by  the 
fact  that  in  some  instances  submucous  abscesses  are  found  in  connection 
with  local  necrosis  of  cartilage,  where  no  opening  in  the  overlying  mucous 
membrane  exists;  in  other  cases  the  necrosis  of  cartilasre  is  secondarv  to 
the  ulcerative  processes. 


ENTERIC    OR   TYPHOID    FEVER.  181 

Necrosis  of  the  nasal  cartilages  has  been  observed,  in  rare  instances,  as 
a  result  of  fever. 

Bronchial  catarrh  is  of  sufficiently  common  occurrence  to  acquire  a 
certain  amount  of  diagnostic  significance.  It  is  sometimes  unattended 
by  cough,  or  by  subjective  symptoms,  and  is  discovered  only  upon  auscul- 
tation. As  a  general  rule  the  cough  is  slight,  and  expectoration  scanty, 
or  altogether  absent.  Exceptionally,  there  is  spasmodic  cough,  with 
paroxysms  of  dyspnoea. 

When  the  catarrhal  processes  affect  the  smaller  bronchial  tubes,  they 
often  give  rise  to  lobular  collapse  and  lobular  pneumonia.  In  a  consider- 
able proportion  of  the  cases  which  terminate  fatally  prior  to  the  end  of 
the  second  week,  death  is  due  to  pulmonary  complications.  Bronchitis, 
usually  associated  with  hypostasis,  is  often  a  troublesome  condition  in  the 
fourth  week,  when  it  may  contribute  to  the  fatal  termination,  or  to  the  in- 
definite retardation  of  the  convalescence. 

Lobular  pneumonia  was  noted  by  Hoffmann'  as  present  in  38  out  of 
250  cases  examined  after  death.  Of  these  38  patients,  3  had  died  in 
the  second  week,  8  in  the  third,  7  in  the  fourth,  6  in  the  fifth,  and  14  at 
a  later  period. 

Hypostatic  congestion  of  the  lungs  and  pulmonary  oedema  arise  in 
consequence  of  the  failure  of  the  circulation.  Hypostasis  develops  itself 
as  soon  as  the  force  of  the  heart  is  notably  reduced.  This  may  occur  in 
the  course  of  the  second,  but  is  common  in  the  third  week.  The  patient 
lies  quietly  upon  his  back,  and  the  influence  of  gravity  upon  the  blood  in 
the  vessels  of  the  lungs  is  added  to  that  of  the  enfeeblement  of  the  circu- 
lation. The  blood  stagnates  in  the  most  dependent  portions  of  the  lung, 
in  which  regions  the  air  is  gradually  forced  out  of  the  alveoli,  and  there 
results  an  airless  condition  of  the  pulmonary  tissue,  not  due  to  inflamma- 
tion, which  is  termed  splenization.  If  a  sluggish  inflammatory  process 
arise  in  this  tissue,  hepatization  results  in  consequence  of  hypostatic 
pneumonia.  These  conditions  are  to  be  recognized  by  the  enfeeblement 
of  the  respiratory  sounds  to  which  they  give  rise,  by  dulness  at  the  bases 
posteriorly,  a  little  more  marked  upon  one  side  than  upon  the  other,  and 
by  the  well-marked  weakness  of  the  heart  with  which  they  are  associated. 
They  are  chiefly  to  be  diagnosticated  from  lobar  pneumonia,  by  the  slight 
degree  of  difference  in  the  two  sides,  by  the  absence  of  rigors  or  increase 
of  fever,  and  by  the  gradual  manner  in  which  the  physical  signs  of  con- 
solidation are  developed.  Pulmonary  hypostasis  aggravates  the  condition 
of  the  patient  by  cutting  off  extensive  areas  of  alveolar  surface,  and  thus 
curtailing  the  function  of  respiration  ;  it  is  also  to  be  viewed  with  appre- 
hension, as  an  indication  of  cardiac  weakness. 

Pulmonary  oedema  is  very  common  in  connection  with  other  affec- 

'  See  Ziemsseo's  Cyclopaedia,  vol.  i. ,  Article  Typhoid  Fever. 


182  THE    CONTINUED    FEVERS. 

tions  of  the  lungs.  When  death  takes  place  by  gradual  failure  of  the 
heart,  it  is  associated  with  the  development  of  extensive  oedema  of  the 
lungs,  and  the  patient  is  drowned  in  the  serum  of  his  own  blood. 

Hemorrhagic  infarcts  occur.  They  are  difficult  of  diagnosis  during 
life.  If  due  to  heart-clot,  of  which  fragments  are  swept  into  branches  of 
the  pulmonary  artery,  they  may  be  absorbed.  They  may,  however,  un- 
dero"o  purulent  changes,  resulting  in  the  formation  of  abscesses,  or  they 
may  result  in  circumscribed  gangrene  of  the  lung.  They  are  apt  to  occa- 
sion pneumonic  infiltration  and  pleurisy,  and  in  all  cases  increase  the 
dangers  of  the  patient's  condition. 

Lobar  pneumonia  is  a  common  complication.  Occurring  in  the  course 
of  the  disease,  it  has  the  character  of  secondary  pneumonia;  the  cough  is 
not  increased,  the  chest-pain  is  absent  or  slight,  and  rusty  sputa  do  not 
occur.  It  is  to  be  recognized  by  the  signs  with  which  its  onset  is  at- 
tended, by  the  sudden  increase  in  fever,  and  by  the  evidences  of  infiltra- 
tion discovered  upon  physical  examination  of  the  chest.  In  rare  cases  it 
occurs  early,  but  it  is  much  more  common  at  the  height  of  the  disease, 
that  is  to  say,  in  the  last  part  of  the  second  or  in  the  third  week,  and  it 
may  not  arise  till  after  convalescence  is  fairly  established.  In  the  last 
case  the  ordinary  characters  of  primary  pneumonia  are  apt  to  be  present. 
When  it  occurs  early,  or  before  the  patient  has  come  under  observation,  this 
complication  may  be  mistaken  for  the  primary  disease.  The  term  "  typhoid 
pneumonia  "  has  been  applied  alike  to  idiopathic  pneumonia  with  "  typhoid  " 
symptoms,  and  to  cases  of  typhoid  fever  in  which  the  pulmonary  compli- 
cations have  been  prominent.  It  is  an  unfortunate  term,  leading  to  no  little 
confusion,  and  richly  deserves  to  be  discarded  from  medical  writings. 

Gangrene  of  the  lung  occasionally  occurs.  It  may  be  diffuse  or  cir- 
cumscribed. The  former  may  result  from  the  breaking-down  of  a  lobar 
infiltration  ;  it  manifests  itself  by  the  ordinary  symptoms,  and  is,  there- 
fore, recognized  during  life.  Circumscribed  gangrene  frequently  follows 
hsemorrhao-ic  infarction;  it  may  result  from  the  necrobiotic  processes  in 
the  tissues  of  patches  of  lobular  pneumonia.  It  usually  remains  circum- 
scribed, and  is  not  recognized  during  life. 

Chronic  'pneumonia^  in  consequence  of  the  delayed  resolution  of  in- 
flammatory products,  not  rarely  supervenes  upon  the  various  pulmonary 
complications  of  enteric  fever.  It  may,  after  a  duration  of  variable  length, 
terminate  favorably  ;  much  more  frequently,  the  infiltrated  portions  of 
luno-  ultimately  break  down  with  the  formation  of  cavities,  and  the 
patient  succumbs  to  rapid  phthisis.  Although  no  exact  statistics  upon 
which  to  base  the  opinion  exist,  it  is  generally  thought  that  consumption 
is  a  much  more  common  sequel  of  enteric  than  of  the  other  fevers.  This 
opinion  is  probably  correct. 

Acute  miliary  tuberculosis  is  an  occasional  sequel.  It  may  be  devel- 
oped immediately  after  the  attack,  or  not  until  the  lapse  of  some  weeks. 


ENTERIC  OR  TYPHOID  FEVER.  183 

Pleurisy  with  more  or  less  abundant  effusion  is  more  frequent  after 
enteric  than  after  typhus  fever.     It  occasionally  results  in  empyema. 

As  has  been  already  pointed  out,  to  the  failure  of  the  power  of  the 
circulation  is  largely  due  many  of  the  complications  of  the  disease.  This 
failure  is  a  direct  result  of  the  degeneration  of  the  muscular  tissue  of  the 
heart,  which  is  to  a  greater  or  less  extent  present  in  all  severe  cases. 
The  general  nutrition  of  the  tissues  is  impaired  because  they  do  not 
receive  their  usual  supply  of  blood,  not  less  than  because  the  supply  is  of 
an  inferior  quality.  The  amount  of  blood  being  decreased  and  the  force  of 
the  circulation  diminished,  it  is  apparent  that  a  slight  amount  of  inflamma- 
tory infiltration  may  cut  off  the  local  supply  altogether,  and  destructive 
ulceration  and  gangrene  readily  ensue.  But  the  mere  slowing  of  the  blood- 
current  within  its  ordinary  channels  gives  rise  to  many  complications  of  im- 
portance.    Those  implicating  the  respiratory  tract  have  been  alluded  to. 

Dilation  of  the  cardiac  ventricles,  both  upon  the  right  and  the  left 
side,  occasionally  occurs  in  consequence  of  the  degeneration  of  their  mus- 
cular walls,  other  recognized  causes  being  absent.  This  sometimes  reaches 
an  extent  that  enables  one  to  diagnosticate  it  during  life.  It  is  more  com- 
mon upon  the  right  than  upon  the  left  side.  In  a  majority  of  cases  termi- 
nating in  recovery,  the  increased  area  of  dulness  recedes  as  the  quality 
of  the  systolic  sound  and  the  force  of  the  impulse  improve.  Excessive 
weakness  of  the  heart,  combined  with  dilatation,  often  leads  to  the  forma- 
tion of  heart-clot.  Ante-mortem  clots  occur  on  both  sides  of  the  heart. 
If  fragments  of  such  clots  are  swept  from  the  right  ventricle  into  the 
branches  of  the  pulmonary  artery,  they  result  in  embolism  and  the  forma- 
tion of  hemorrhagic  infarcts;  while  the  detachment  of  fragments  from  a 
clot  in  the  left  ventricle  produces  embolism  somewhere  in  the  course  of 
the  general  circulation,  oftenest  in  the  spleen  or  kidneys. 

To  the  same  cause,  namely,  weakening  of  the  force  of  the  circulation, 
we  must  refer  the  occurrence  of  venous  thrombosis,  which  is  most  fre- 
quently met  with  in  the  femoral  vein.  It  is  a  complication  of  moderately 
frequent  occurrence.  Murchison  encountered  it  in  fully  one  per  cent,  of 
his  cases.  Of  17  instances  in  which  it  occurred  under  his  observation, 
it  was  restricted  to  the  left  leg  in  14;  to  the  right  in  1;  and  both  limbs 
were  implicated  in  2.  Of  these  17  cases,  3  proved  fatal,  and  it  is  of  in- 
terest to  note  that  they  were  cases  in  which  the  evidences  of  the  gravest 
impairment  of  nutrition  existed;  thus  one  died  of  intestinal  hemorrhage 
and  pleural  effusion  ;  one  in  consequence  of  extensive  bed-sores  and 
sloughing  of  the  nates,  and  the  third  proved  fatal  six  months  after  the 
commencement  of  the  fever,  death  being  preceded  by  the  occurrence  of 
jaundice,  albuminuria,  and  the  signs  of  a  very  feeble  heart. 

In  the  hospital  at  Basle,  31  cases  of  thrombosis  of  the  veins  of  the 
lower  extremity  occurred  among  1,743  enteric  fever  patients,  the  majority 
being  among  men.     This  complication  made  its  appearance  commonly 


184  THE  CONTINUED  FEVEES. 

during  convalesence,  but  in  a  few  instances  in  the  third  or  fourth  week 
of  the  fever.  In  24  cases,  16  occurred  in  men,  8  in  women;  18  impli- 
cated the  femoral  vein,  3  the  saphena,  and  1  the  popliteal.  Thrombosis 
of  the  femoral  vein  on  both  sides  occurred  twice,  four  times  on  the  right 
side  alone,  and  twelve  times  on  the  left  alone.  The  greater  frequency  of 
the  occurrence  of  this  accident  upon  the  left  side  has  been  explained  by 
the  fact  that  the  left  common  iliac  vein,  being  crossed  by  the  right  com- 
mon iliac  artery,  does  not  admit  of  so  ready  a  flow  of  blood  as  the  vessel 
of  the  other  side  (Liebermeister).  Of  the  31  cases  referred  to,  only  two 
proved  fatal.  The  foregoing  statistics  show  that  the  mortality  to  be  at- 
tributed to  this  complication  is  low,  if  due  regard  be  paid  to  the  fact 
that  it  occurs  late  in  the  disease,  and  is  of  itself  an  evidence  of  grave 
impairment  of  the  heart-power,  and  of  the  general  nutrition  of  the  body. 
Spontaneous  gangrene,  in  consequence  of  arterial  thrombosis,  is  much 
less  common  in  enteric  than  in  typhus  fever. 

Endo-  and  pericarditis  are  very  rare  as  complications  or  sequels  of  en- 
teric fever. 

The  complications  and  sequels  arising  in  consequence  of  affections  of 
the  intestinal  tract  are  numerous;  some  of  them  are  among  the  most  se- 
rious connected  with  the  disease. 

Ulceration  of  the  tongue  and  of  the  buccal  mucous  memhrane  are 
noted  as  of  common  occurrence  by  systematic  writers  on  enteric  fever. 
It  would  appear  that  these  complications  are  more  common  in  Europe 
than  in  this  country.  They  frequently  lead  to  gangrene,  which  is  usually 
superficial,  but  may  be  deep,  extensive,  and  destructive. 

Catarrh  of  the  mucous  membrane  of  the  pharynx  and  nasopharynx 
is  of  sufficiently  common  occurrence  to  merit  consideration  as  a  symptom 
rather  than  as  a  complication,  and  has  already  been  spoken  of  as  such. 
Diphtheritic  processes  occasionally  involve  the  tonsils,  half  arches,  the 
lower  part  of  the  pharynx,  and  the  upper  air-passages.  All  these  pro- 
cesses may,  by  extension,  implicate  the  Eustachian  tube  and  middle  ear, 
and  give  rise  to  serious  lesions  of  the  organ  of  hearing,  and  more  or  less 
permanent  deafness. 

Difficidty  in  sxcallowing  may  arise  from  mere  dryness  of  the  throat, 
from  any  of  the  inflammatory  infections  of  the  pharynx,  which  have  just 
been  spoken  of,  or  in  consequence  of  more  or  less  perfectly  developed 
palsy  of  the  muscles  of  deglutition.  In  children  it  appears  to  be  occa- 
sionally due  to  pharyngeal  hyperrpsthesia,  attempts  to  swallow  occasion- 
ing spasmodic  cough,  with  the  rejection  of  fluids  through  the  nostril. 

Swelling  of  the  parotid  glands  occasionally  occurs.  It  is  much  less 
common  in  this  country  than  in  Europe.  The  enlargement  occasionally 
undergoes  resolution  without  suppuration.  More  commonly  it  terminates 
in  the  formation  of  pus,  at  various  points  in  the  gland  itself,  and  in  the 
connective  tisssue  overlying  it,  and  is  then  very  often  fatal.     It  usually 


ENTERIC  OR  TYPHOID  FEVER.  185 

implicates  one,  much  less  commonly  both  sides.  Suppuration  of  the 
other  salivary  glands  does  not  occur. 

Jaundice  occurs  in  a  small  proportion  of  the  cases,  and  is  a  symptom 
of  great  gravity.  Murchison  met  with  it  in  three  cases,  all  of  which 
proved  fatal,  although,  in  one  of  them,  the  jaundice  had  disappeared  be- 
fore death.  Louis,  Frerichs  and  Jenner  have  also  recorded  cases  of  jaun- 
dice, all  of  which  proved  fatal.  Out  of  600  cases,  Griesinger  observed 
jaundice  in  10,  in  several  of  whom  recovery  occurred.  Jaundice  is  of  much 
less  common  occurrence  in  typhoid  fever  than  in  any  other  acute  febrile 
affection.  It  is  sometimes  due  to  an  extension  of  the  catarrhal  processes 
from  the  intestine  to  the  biliary  passages.  In  a  certain  proportion  of  the 
cases,  however,  it  is  to  be  attributed  to  the  parenchymatous  degeneration 
of  the  liver,  incident  to  the  prolonged  fever.  This  degeneration  may 
reach  an  intensity  so  great  as  to  amount  to  a  distinct  complication,  pre- 
senting the  group  of  symptoms  characteristic  of  icterus  gravis  or  acute 
yellow  atrophy  of  the  liver  (Liebermeister).  In  two  of  Murchison's  cases 
the  liver  is  noted  as  havingr  been  small  and  its  secretins:  cells  loaded  with 
oil.  Other  observers  speak  of  the  occurrence  of  a  high  grade  of  fatty 
degeneration  of  the  liver,  in  fatal  cases  attended  with  jaundice.  Abscesi 
of  the  liver  belongs  to  the  rarer  of  the  complications  of  enteric  fever. 

The  consideration  of  intestinal  hemorrhage  belongs  properly  to  the 
discussion  of  the  symptoms  of  the  disease  rather  than  its  complications, 
and  has  already  received  attention  in  a  foregoing  division  of  our  subject. 

Closely  related  to  this  subject,  however,  as  it  is  one  of  the  accidents  of 
the  ulceration,  is  perforation  of  the  intestine.  This  is  the  most  important 
and  dangerous  complication  of  the  disease,  and  is  met  with,  in  the  course 
of  no  other  acute  disease,  with  the  exception  of  rare  cases  of  dysentery. 
Of  1,721  autopsies  recorded  by  various  observers  in  Britain  and  on  the  con- 
tinent, Murchison  found  196  instances  of  perforation,  that  is  to  say,  11.38 
per  cent,  of  the  fatal  cases.  The  same  observer  states  that  it  occurred  in 
38  of  1,580,  or  3.04  per  cent,  of  the  cases  under  his  care;  it  occurred  in 
14  out  of  600  cases,  or  2.3  per  cent,  of  the  cases  observed  by  Griesinger. 

Perforation  is  much  more  common  in  males  than  in  females.  In  gen- 
eral terms,  it  may  be  stated  that  age  does  not  especially  influence  the 
liability  to  this  accident,  although  some  authorities  entertain  the  opinion 
that  it  occurs  less  frequently  in  children  than  in  adults,  and  that  it  is 
much  more  rare  in  persons  over  forty  years  of  age  than  in  the  earlier 
periods  of  life. 

Intestinal  perforation  occurs  by  far  most  frequently  in  the  severest 
cases  of  the  disease,  and  particularly  in  those  in  which  diarrhoea,  tympany 
and  abdominal  pains  have  been  prominent  symptoms.  In  many  instances 
intestinal  hemorrhage  has  preceded  the  occurrence  of  perforation.  On 
the  other  hand,  it  is  of  the  utmost  importance  to  bear  in  mind  that  this  ac- 
cident may  occur  in  cases  of  the  mildest  description,  and  in  those  in  which 


186  THE  CONTINUED  FEVERS. 

the  bowels  have  been  constipated  or  confined  throughout.  It  has  even 
occurred  where  the  intestinal  ulceration  has  been  limited  to  a  few  points. 

Perforation  is  most  liable  to  occur  during  the  third,  fourth,  or  fifth 
week  of  the  disease,  although  it  sometimes  occurs  at  a  later  period. 
Out  of  58  cases  observed  by  Murchison,  four  occurred  in  the  second  week; 
13  in  the  third;  16  in  the  fourth;  13  in  the  fifth;  8  in  the  sixth;  one  in 
the  eighth;  one  in  the  ninth,  and  one  as  late  as  the  tenth  week.  Of  22 
cases  noted  by  Liebermeister,  perforation  took  place  in  2  at  the  end  of 
the  second  week;  in  6  in  the  third  week;  in  2  in  the  fourth;  in  6  in  the 
fifth;  twice  each  in  the  sixth  and  seventh  weeks,  and  twice  at  a  later 
period.  According  toNiicke,'  of  183  cases,  84  occurred  during  the  course 
of  the  first  three  weeks,  and  99  at  a  later  period. 

One  of  the  more  important  lessons  conveyed  by  the  foregoing  statis- 
tics relates  to  the  danger  of  perforation  not  only  after  the  termination  of 
the  fever,  but  even  long  after  convalescence  has  been  fairly  established. 
Instances  are  not  rare  in  which  perforation  has  occurred  after  the  patient 
has  been  allowed  to  leave  his  room,  or  even  to  go  about,  and  was  in  every 
respect  apparently  almost  well. 

The  earlier  perforations  take  place  about  the  time  of  the  separation 
of  the  sloughs  from  the  ulcerated  areas  of  the  intestine.  The  later  per- 
forations are  due  to  the  extension  of  ulcerations  that  show  no  disposition 
to  heal.  Among  the  immediate  causes  of  perforation  may  be  enumerated 
indigestible  food,  hardened  fecal  masses,  ascarides,  over-distension  of  the 
gut  with  gas  or  faeces,  vomiting,  straining  at  stool,  and  sudden  changes 
of  posture.  When  the  ulceration  has  extended  to,  or  has  implicated  the 
serous  membrane,  the  most  insignificant  causes  may  produce  this  acci- 
dent. The  vermicular  movement  following  the  injudicious  administra- 
tion of  a  purgative,  or  excited  by  an  enema,  is  sufficient  to  rupture  the 
thinned  wall  of  the  bowel.  The  most  frequent  seat  of  the  opening  is  at 
the  lower  portion  of  the  ileum.  It  may  occur  higher  up  in  the  small  in- 
testine, or  in  the  caput  coli,  particularly  at  the  appendix  vermiformis. 
From  the  statistics  of  Niicke,  we  find  that  of  133  cases,  perforation  oc- 
curred in  the  ileum  106  times;  in  the  colon  12  times,  and  in  the  appen- 
dix 15  times.  Of  20  cases  observed  by  Hoffmann,  the  perforation  was 
located  in  the  colon  once;  in  the  appendix  twice;  in  the  small  intestine 
18  times.  In  one  case,  the  perforation  being  double,  was  counted  twice. 
The  position  of  the  18  perforations  of  the  small  intestine  was  as  follows: 
once  immediately  above  the  ileo-caecal  valve;  four  times  at  from  four  to 
six  inches  above  it;  nine  times  at  from  eight  to  twenty  inches;  twice  at 
from  four-and-a-half  to  six  feet;  once  ten  feet;  and  in  one  remarkable 
case  there  were  from  25  to  30  perforations  in  the  jejunum. 

'  Ueber  Darmperforation  ira  Typhus  Abdominalis.     Wiirzburg,  1873.     This  work 
is  referred  to  by  Liebermeister. 


ENTERIC  OR  TYPHOID  FEVER.  187 

The  perforation  is  usually  a  small  opening  in  the  serous  coat,  varying 
in  size  from  a  pin's  head  to  a  split  pea  :  it  forms  the  apex  of  a  funnel- 
shaped  ulceration  at  some  point  in  a  Peyer's  patch,  and  is  then  surrounded 
by  more  superficial  ulceration  ;  or,  and  this  is  less  frequently  the  case,  it 
occurs  in  a  solitary  follicle.  The  margins  of  the  opening  are  rarely  torn 
or  ragged,  but  usually  present  a  *  punched-out '  appearance,  and  are  often 
surrounded  on  the  peritoneal  surface  by  a  narrow  ring  of  recent  lymph. 

The  immediate  result  of  perforation  is  acute  peritonitis,  which  is,  in 
by  far  the  greatest  number  of  cases,  diffuse,  although  in  rare  instances 
the  extension  of  the  inflammation  has  been  discovered  to  have  been  lim- 
ited by  rapidly  formed  adhesions  resulting  in  the  formation  of  a  circum- 
scribed peritoneal  abscess  ;  or  a  minute  opening  has  been  blocked  by  ad- 
hesions formed  with  the  abdominal  wall,  some  adjacent  coil  of  intestine, 
or  a  fold  of  mesentery. 

The  patient  experiences,  at  the  moment  of  perforation,  an  intense  sud- 
den pain,  which  rapidly  extends  over  the  whole  abdomen,  but  of  which 
the  focus  is  at  first  in  the  right  iliac  fossa.  This  pain  may  be  accompanied 
by  rigors  of  greater  or  less  intensity,  or  it  may  occur  without  them. 
Tympany,  if  present,  usually  increases,  or  if  it  have  previously  subsided, 
recurs.  The  abdomen  becomes  exquisitely  tender;  the  patient  lies  upon 
his  back  with  his  legs  drawn  up,  his  face  drawn  and  pinched.  Vomiting 
often  occurs.  The  pulse  is  small,  rapid,  or  uncountable;  the  breathing 
shallow  and  thoracic;  there  is  tormenting  thirst  and  mostly  suppression  of 
urine.  Shock  commonly  occurs,  and  the  patient  falls  into  a  state  of  col- 
lapse, with  cold  extremities,  sweating,  and  a  more  or  less  decided  fall  of 
temperature.  With  this  fall  the  mental  state  of  the  patient  improves,  and 
he  may  even  pass  from  stupor  into  a  state  of  mental  clearness.  In  sud- 
den and  severe  cases  death  sometimes  takes  place  in  the  course  of  a  few 
hours,  the  mind  remaining  clear  until  the  end.  Much  more  commonly  the 
patient  survives  the  shock  and  the  temperature  rises  again;  but  the  symp- 
toms of  peritonitis  overshadow  those  of  the  primary  disease  and  he  per- 
ishes in  the  course  of  from  two  to  four  days.  In  a  considerable  propor- 
tion of  the  cases  perforation  takes  place  without  the  occurrence  of  distinct 
symptoms  of  peritonitis,  and  death  may  result  from  this  cause  in  cases 
where  it  has  not  been  suspected.  Its  advent  may  be  announced  by  no 
other  symptoms  than  a  sudden  deepening  of  the  prostration,  an  increase 
in  the  pulse  frequency  and  an  abrupt  temperature-rise;  or  sudden  vomiting, 
and  coldness  of  the  extremities,  may  be  the  only  changes  observed.  Death 
may  in  some  few  cases  be  delayed  for  several  days  or  weeks,  and  there  is 
abundant  evidence  to  prove  that  in  rare  cases  recovery  from  this  accident 
has  taken  place.  If  this  statement  rested  upon  no  other  basis  than  that 
of  the  occasional  sudden  occurrence  of  the  symptoms  of  peritonitis  in  the 
advanced  stages  of  enteric  fever,  in  patients  in  whom  permanent  recovery 
ultimately  took  place,  it  would  be  open  to  the  criticism  that  the  peritoni- 


188  THE  CONTINUED  FEVERS. 

tis  might  be  due  to  other  causes  than  perforation.  But  it  is  supported 
by  more  direct  evidence  derived  from  cases  where,  after  the  subsidence 
of  the  symptoms  following  perforation,  death  has  resulted  from  other 
causes,  and  the  perforation  has  been  found  closed  by  adhesion  to  some  ad- 
jacent structure. 

Buhl '  relates  the  case  of  a  patient  who  had  symptoms  of  perforation  on  the  twenty- 
fifth  day  of  enteric  fever  and  was  recovering,  but  died  twenty  days  later,  of  profuse 
hemorrhage ;  a  perforation  was  found  completely  closed  by  adhesions  to  the  mesen- 
tery. 

Analogous  cases  have  been  reported  by  many  observers.  Recovery 
has  in  many  instances  taken  place  after  the  formation  of  a  circumscribed 
peritoneal  abscess,  the  contents  of  which  have  after  a  time  been  evacu- 
ated either  by  the  bowel,  or  by  an  external  opening. 

A£Eections  of  the  genito-urinary  tract  occur  as  complications  of  enteric 
fever. 

Transitory  albuminuria  occurs  in  nearly  one-third  the  cases.  It  is, 
therefore,  under  ordinary  circumstances  to  be  looked  upon  as  a  symptom 
rather  than  a  complication.  Acute  Bright's  disease  occasionally  occurs, 
but  is  far  less  frequent  after  enteric  fever  than  after  scarlatina.  Accord- 
ing to  Liebermeister  it  is  even  less  frequent  after  enteric  fever  than  after 
pneumonia,  facial  erysipelas,  or  measles. 

HcBmaturia  occurs  in  connection  with  hemorrhages  from  the  other 
mucous  tracts,  and  is  not  unfrequently  one  of  several  evidences  of  the 
hemorrhagic  diathesis. 

Catarrh  of  the  bladder  not  rarely  occurs  during  convalescence.  It  is 
commonly  slight  and  speedily  passes  away;  sometimes  it  is  acute  and 
troublesome.  It  is  chiefly  to  be  attributed  to  over-distention  of  the  blad- 
der during  the  course  of  the  fever.  But  this  is  not  always  the  case;  at 
this  time  there  is  under  my  care  a  gentleman  convalescent  from  a  light 
attack  of  typhoid,  who  still  suffers  from  mild  vesical  catarrh,  although  con- 
valescence is,  in  other  respects,  complete.  There  was  not  the  slightest 
undue  retention  during  the  whole  course  of  his  sickness.  Orchitis  and 
epididymitis  may  occur  without  previous  gonorrhoea. 

Menstruation  often  occurs  prematurely  during  the  course  of  the  attack, 
and  is,  as  a  rule,  more  profuse  than  is  habitual  with  the  patient. 

Pregnancy  affords  a  relative,  but  by  no  means  complete,  immunity 
from  the  attack.  It  undoubtedly  adds  to  the  danger  of  the  patient,  but 
is  not  to  be  looked  upon  as  a  formidable  complication.  Of  fourteen  cases 
observed  by  Murchison,  ten  recovered;  of  these  ten,  two  carried  the  child 
throughout  the  attack;  the  four  fatal  cases  aborted. 

Herpes  labialis  is  very  rare. 

'  Quoted  by  Murchison. 


ENTERIC  OR  TYPHOID  FEVER.  189 

Facial  erysipelas  occasionally  occurs  at  the  height  of  the  attack  or 
during  convalescence.     It  is  a  serious  complication. 

Hemorrhages  into  the  ski7i,  true  petechise,  vibices  and  the  like,  occur 
in  persons  subject  to  the  hemorrhagic  diathesis,  or  who  develop  it  in  thqi 
course  of  the  disease.     They  may  also  occur  in  others,  but  are  rare. 

Soils  and  abscesses  in  the  integuments,  the  muscles,  or  the  intermus-* 
cular  connective  tissue  are  met  with  in  a  small  proportion  of  the  cases 
during  convalescence.  Much  more  rarely,  suppuration  of  the  lymphatic 
glands  of  the  axilla,  and  in  other  regions,  takes  place. 

£ed-sores  constitute  a  common  and  troublesome  complication  in  severei 
cases.  They  are  far  more  frequent  in  enteric  fever  than  in  any  other 
acute  disease,  a  fact  that  is  to  be  explained  by  the  long  duration  of  this, 
fever,  the  great  emaciation,  the  feebleness  of  the  circulation  and  the  grave 
general  impairment  of  nutrition.  They  occur  not  only  over  the  sacrum 
and  trochanters,  but  also  at  the  elbows,  heels,  and  occiput, 

77ie  hair /alls  during  convalescence.  The  new  hair  is  often  lacking  in 
lustre,  but  gradually  acquires  a  normal  appearance. 

The  nails  both  of  the  hands  and  the  feet  show  markings  that  indicate 
the  impaired  nutrition  of  the  tissues  during  the  attack.  These  markings 
consist  of  bands  or  furrows  across  the  whole  width  of  the  nail.  The  por- 
tion of  the  nail  developed  during  the  attack  is  duller  than  the  rest,  rough, 
white,  and  more  or  less  thinned.  Similar  changes  occur  during  the 
course  of  other  severe  febrile  diseases.  They  have  been  described  by 
Vogel,*  Longstreth,"  and  others. 

Among  the  more  important  of  the  complications  and  sequels  of  enteric 
fever  are  those  referable  to  the  nervous  system.  The  importance  of  this 
group  of  secondary  affections  arises  from  their  gravity  rather  than  from 
the  frequency  of  their  occurrence. 

Fff^usions  0/ blood  are  noted  as  of  rare  occurrence.  They  may  take 
place  into  the  meninges,  or  into  the  substance  of  the  brain  itself,  and 
usually  occur  at  the  height  of  the  disease.  A  previous  condition  of  de- 
generation of  the  walls  of  the  vessels  is  a  necessary  predisposing  cause 
of  this  accident.  Liebermeister  states  that  slight  effusions  into  the  men- 
inges give  rise  to  no  symptoms,  but  that  considerable  effusions  occasion 
symptoms  of  compression;  while  effusion  into  the  substance  of  the  brain 
is  followed  by  the  symptoms  of  apoplexy. 

Meningitis  occurs  but  rarely  in  the  course  of  enteric  fever.  The  cere- 
bral symptoms  attendant  upon  ordinary  cases  of  the  disease  are  in  no  way 
dependent  upon  inflammatory  processes  affecting  any  part  of  the  nervous 
system.     A  number  of  cases  are  recorded  in  which  meningitis  has  oc- 

'  Die  Nagel  nach  fiebethaften  Krankheiten.  By  A.  Vogel :  Deutschea  Archiv  fiii 
klin.  Med.,  viij.     1870. 

-'  Trans.  College  of  Physicians  of  Philadelphia.     1877. 


190  THE  CONTINUED  FEVERS. 

curred  in  the  course  of  the  disease,  or  during  convalescence,  in  conse- 
quence of  disease  of  the  internal  ear,  or  of  the  development  of  acute 
tuberculosis.  Murchison  states  that  meningitis  may  occur,  in  rare  in- 
stances, independently  of  such  causes. 

Feebleness  of  intellect  and  attacks  of  mania  show  themselves  in  a 
small  proportion  of  the  cases  during  convalescence,  or  at  a  considerable 
time  after  apparent  recovery.  They  are  most  apt  to  appear  in  persons 
who  have  a  hereditary  tendency  to  mental  disorders.  These  affections 
are  not  peculiar  to  enteric  fever,  but  they  occasionally  occur  after  other 
acute  febrile  disorders.  They  are  commonly  transient,  lasting  a  few 
days  or  weeks,  less  often  several  months;  but  all  authorities  agree  in 
stating  that  they  result  in  ultimate  recovery. 

Palsy  is  an  occasional  sequel  of  enteric  fever.  It  presents  all  the  va- 
rieties met  with  after  the  other  acute  diseases,  and  may  occur  during  the 
course  of  the  attack,  or  not  until  several  weeks  after  the  commencement 
of  convalescence.  Trousseau  mentions  a  case  of  typhoid  fever,  in  which 
the  begii)ning  of  the  disease  announced  itself  by  a  violent  pain  in  the 
lumbar  region,  and  a  true  paraplegia  such  as  is  occasionally  seen  in  variola. 
The  most  common  form  is  paraplegia;  but  hemiplegia,  paralysis  of  the 
portio  dura,  strabismus,  and  paralysis  of  individual  spinal  nerves,  may  also 
occur. 

Laudouzy '  has  collected  cases  illustrating  the  more  common  forms. 
Among  these  is  one  case  of  enteric  fever  in  a  soldier,  where  paraplegia 
began  gradually  during  convalescence  about  the  seventh  week  after  ad- 
mission to  the  hospital.  There  was  also  squint  (paralysis  of  the  left  exter- 
nal oblique  muscle),  which  lasted  six  or  eight  days,  and  retention  of  urine, 
which  made  the  use  of  the  catheter  necessary.  The  urine  was  albumi- 
nous. This  patient  recovered.  A  second  patient,  a  woman  twenty-nine 
years  of  age,  suffered  from  paraplegia  nearly  three  months  after  the  de- 
fervescence; there  was  vesical  and  rectal  palsy,  and  paralysis  of  the  velum 
palati;  recovery  took  place.  Other  cases  are  detailed  in  which  hemi- 
plegias, paralyses  of  the  dilator  muscles  of  the  glottis,  necessitating 
tracheotomy,  aphasia,  etc.,  occurred.  The  greater  frequency  of  aphasia 
among  children  than  among  adults  has  attracted  the  attention  of  all  ob- 
servers. More  frequently  the  paralytic  symptoms  are  developed  at  the 
period  of  decline  of  the  fever,  or  in  the  early  days  of  convalescence. 
This  group  of  paralyses  has  a  natural  tendency  to  recovery.  Paraplegias, 
hemiplegias,  aphasia,  the  various  local  and  limited  paralyses,  due  to  le- 
sions of  the  nervous  system  incident  to  typhoid  fever,  disappear  generally 
in  the  course  of  some  weeks  or  months. 

There  is,  however,  another  group  of  paralyses  encountered  as  com- 

'  Des  paralysies  dans  les  maladies  aignes.  Par  Dr.  Louis  Laudouzy.  Paris,  1880. 
See  also  Bailly :  Paralysies  coneecutives  a  quelques  maladies  aigues.     Paris,  1872. 


ENTERIC  OR  TYPHOID  FEVER.  191 

plications  or  sequels  of  enteric  fever,  of  which  the  foregoing-  statement 
is  not  true.  The  fever  is  not  the  primary  cause  of  the  affections  of  the 
nervous  system;  it  merely  calls  forth  an  individual  predisposition  already 
existing,  and  the  future  of  the  case  depends  upon  the  pathological  con- 
ditions underlying  the  paralysis,  that  is,  upon  the  individual  peculiari- 
ties of  the  patient.  Palsies  in  such  patients  may  result  from  attacks  of 
little  severity. 

Paralysis  of  the  bladder  is  not  uncommon.  In  this  respect  enteric 
fever  differs  from  diphtheria,  which  is  rarely  followed  by  vesical  paraly- 
sis— a  difference  that  is  remarkable  in  view  of  the  fact  that  in  other  re- 
spects the  palsies  following  these  two  diseases  closely  resemble  each  other 
in  kind,  though  not  in  frequency. 

Finally,  we  must  include  among  the  paralyses  the  sudden  death  that 
occasionally  takes  place  in  the  advanced  stages  of  the  disease,  from  arrest 
of  the  heart  in  diastole,  and  the  paralysis  of  accommodation,  which  is 
often  present  in  the  early  days  of  convalescence. 

Neuralgias  and  disturbances  of  sensation  are  less  frequent  after  enteric 
fever  than  after  some  other  acute  affections. 

The  organs  of  special  sense  are  occasionally  the  seat  of  affections  that 
result  directly  or  indirectly  from  enteric  fever.  Otorrhcea  is  by  no  means 
rare,  especially  in  children.  Inflammatory  affections  of  the  internal  ear 
occasionally  result  in  meningitis. 

Deafness,  independently  of  destructive  inflammation  of  the  ear,  occa- 
sionally persists. 

Paralysis  of  accommodation,  amMyopic  conditions,  and  even  slough- 
ening  of  the  cornea,  occur  in  rare  instances,  and  are  to  be  referred  to 
lowered  nutrition. 

It  is  often  a  long  time  before  the  patient,  emerging  from  a  sever© 
attack  of  enteric  fever,  regains  his  previous  health.  He  may  gain  rapidly 
in  flesh  and  present  all  the  appearances  of  vigorous  health,  yet  lack  the 
ability  to  sustain  any  but  the  most  moderate  physical  or  mental  effort. 
As  a  rule,  in  such  cases,  the  normal  standard  of  health  is  gradually  re- 
gained. It  is  a  remarkable  fact  that  the  personal  habit  of  the  individual 
occasionally  undergoes  marked  changes  after  a  severe  attack  of  enteric 
fever,  that  is  to  say,  a  lean  person  may  exhibit  a  tendency  to  corpulence, 
or  a  fat  person  become  lean;  and  it  is  even  more  remarkable  that  changes 
in  disposition  also  sometimes  occur. 

The  patient  may,  however,  remain  permanently  weak  and  ansemic,  and 
continue  to  emaciate  without  obvious  cause,  or  the  existence  of  any  dis- 
tinct, local,  or  constitutional  affection.  Cases  occasionally  prove  fatal  in 
this  way,  months  after  the  cessation  of  the  fever,  and  after  death  no 
lesion  is  discovered,  except  an  abnormally  smooth  appearance  of  the  mu- 
cous membrane  of  the  ileum,  and  a  shrivelled  condition  of  the  mesenteric 
glands  (Murchison). 


192  THE    CONTINUED    FEVERS. 


Varieties. 


The  numerous  forms  attributed  to  typhoid  fever  are,  for  the  most  part, 
merely  differences  in  the  mode  of  onset,  or  in  the  prominences  of  certain 
symptoms  or  groups  of  symptoms.  The  form  called  ^^  bilious"  is  only 
a  typhoid,  which  begins  witu  gastro-duodenal  catarrh,  implicating  the 
biliary  passages,  and  which,  therefore,  presents  among  the  number  of  its 
initial  symptoms,  catarrhal  Jaimdice,  and  all  the  accidents  which  are 
associated  with  that  conditiou,  notably  nausea  and  vomiting.  After  sev- 
eral days,  rarely  more  than  seven,  these  epiphenomena  disappear,  and  the 
typhoid  fever  runs  its  ordinary  course,  sometimes  mild,  sometimes  se- 
vere, but  in  such  a  manner  that  no  constant  relation  can  be  established  be- 
tween this  mode  of  beginning  and  the  ulterior  evolution  of  the  sickness 
(Jaccoud). 

The  form  called  "  mucous  "  and  the  form  called  "nervous  "  are  separa- 
ble from  the  disease,  as  it  is  met  with  in  general,  by  no  more  warrantable 
])riiiciple  of  division;  and  to  distinguish  an  ataxic  from  an  adynamic  form, 
or  other  varieties  based  upon  the  prominence  of  particular  symptoms, 
such  as  an  abdominal  variety,  a  thoracic  variety,  or  a  cerebro-spinal  va- 
riety, is  neither  scientific  nor  convenient,  but  only  serves,  both  at  the 
bedside  and  for  purposes  of  description,  to  darken  counsel.  Such  methods 
of  classification  are  to  be  discarded. 

A  great  variety  of  forms  of  enteric  fever  is,  however,  met  with. 
Many  of  these  are  clearly  to  be  referred  to  the  varying  degree  of  inten- 
sity with  which  the  specific  poison  of  the  disease  acts  upon  different  in- 
dividuals; others  are  to  be  referred  to  the  relative  intensity  of  its  action 
in  producing  local  or  constitutional  effects,  and  still  others  to  individual 
peculiarities  on  the  part  of  the  patient. 

Hence,  we  find,  upon  the  first  principle  of  division,  a  series  of  cases 
ranging  from  the  mildest  affections  attributable  to  the  especial  cause  of 
enteric  fever,  to  the  gravest  forms  of  the  typical  disease;  upon  the  second, 
a  series  in  which  the  cases  vary  according  to  the  relative  prominence  of 
the  intestinal  disease,  or  the  constitutional  disturbance  (zymosis),  the 
former  predominating  in  some  instances,  the  latter  in  others;  and  again, 
we  observe  that  enteric  fever  presents  notable  differences  in  its  course 
and  evolutions  at  different  points  of  life. 

Without  attempting  a  closer  analysis  of  the  forms,  we  may  divide  the 
cases  into  typical  and  atypical,  or,  with  Liebermeister,  into  perfect  and 
imperfect. 

The  typical  or  perfectly  developed  cases  present  the  complexus  of 
symptoms  already  described  as  constituting  the  clinical  history  of  the  dis- 
ease, and  further  illustrated  in  the  analysis  of  the  symptoms,  and  in  the 
consideration  of  the  complications  and  sequels. 


ENTERIC  OR  TYPHOID  FEVER.  193 

The  atypical  or  imperfect  forms  constitute,  in  most  epidemics,  a  large 
proportion  of  the  cases,  and,  when  the  attention  of  physicians  is  more 
closely  turned  to  the  study  of  enteric  fever  from  an  etiological  as  well  as 
from  a  clinical  standpoint,  they  will  be  found,  I  believe,  to  be  much  more 
common  where  the  disease  is  endemic  than  has  usually  been  thought. 
The  cases  are  partly  due  to  mild  infection,  or,  to  use  an  expression 
already  employed  in  this  work,  in  speaking  of  other  fevers,  the  smallness  of 
the  dose  of  the  fever-producing  principle;  partly  to  an  imperfect  suscepti- 
bility on  the  part  of  the  patient. 

Those  cases  which  approach  most  nearly  to  the  typical  form  of  T.lie 
disease  are  to  be  grouped  as  the  mild  cases.  A  second  group  is  consti- 
tuted by  the  abortive  cases,  and  following  the  lightest  forms  are,  first,  the 
cases  of  intestinal  catarrh  with  fever,  and  finally  those  of  afebrile  intesti- 
nal catarrh. 

The  mild  cases  present  the  symptoms  of  the  typical  disease  modified 
as  respects  intensity,  and  in  particular  is  this  true  of  the  febrile  move- 
ment, which  is  of  lower  grade.  The  commencement  of  the  attack  is 
usually  gradual  ;  there  are  prodromes,  which  pass  step  by  step  into  the 
declared  disease.  Chilly  sensations  may  occur;  a  decided  chill  is  unusual. 
There  is  headache,  diarrhoea;  the  nose  may  bleed,  and  the  eruption  ap- 
pears or  not,  as  the  case  may  be.  Upon  the  fourth  or  fifth  day  the  tem- 
perature may  reach  40°  C.  (104°  F.),  but  it  rarely  exceeds  that  point,  and 
much  more  commonly  does  not  attain  it.  The  temperature-range  corre- 
sponds to  that  of  the  typical  form,  save  that  upon  corresponding  days  it 
is  about  a  degree  lower.  The  duration  of  this  form  may  be  four  full 
weeks;  it  is  perhaps  oftener  less  than  this,  each  of  the  four  periods  not 
exceeding  four  or  five  days.  The  febrile  movement  corresponds  to  the 
primary  and  the  secondary  fever  of  the  fully  developed  disease.  The  in- 
testinal lesions  do  not  undergo  resolution,  but  go  on  to  sloughing.  Ac- 
cording to  Jiirgensen,'  the  spleen  is  enlarged  in  the  mildest  cases. 

The  latent,  or  ambulatory  form  {^calking  typhoid)  belongs  to  this 
group.  Jiirgensen  is  of  the  opinion  that  walking  typhoid  (typhus  ambu- 
latorius)  is  nothing  more  than  mild  typhoid  (typhus  levissimus)  prolonged 
by  repeated  errors  in  diet.  In  this  form  all  the  symptoms  are  mild,  the 
fever  shows  itself  only  in  general  malaise,  prostration,  and  elevation  of 
temperature,  yet  the  sickness  extends  over  three  or  four  weeks,  and  the 
intestinal  lesion  proceeds  to  sloughing  and  ulceration.  Herein  lies  the 
danger  of  this  form  of  the  disease.  Tlie  patient  regards  himself  as  suffer- 
ing from  some  slight  indisposition,  a  "  cold,"  or  a  "  bilious  attack,"  and 
continues  to  go  about  in  a  wretched  way,  or  even,  if  he  be  a  person  of 
determined  will,  to  attend  to  his  ordinary  occupations,  and  to  eat  such 


'  Ueber  die  leichteren  Formen  des  Abdominaltyphus.     Sammlung  kliniscber  Vor- 
trage.  No.  61.     Leipsic. 
13 


194  THE  CONTINUED  FEVERS. 

food  as  his  appetite  permits,  until  sudden  delirium  reveals  to  his  friends 
the  serious  character  of  his  illness,  a  profuse  hemorrhage  occurs,  or,  and 
this  is  still  more  common,  symptoms  of  perforation  supervene,  and  are 
followed,  after  a  few  hours,  by  death.  Occasionally  more  fortunate  pa- 
tients of  this  class  come  under  the  observation  of  the  physician,  and  the 
thermometer  reveals  a  temperature  of  40°  C.  (104°  F.)  or  higher,  and  the 
history  of  the  case  and  ensemble  of  symptoms  show  the  disease  to  be  in 
its  third  or  fourth  period. 

The  abortive  form  appears  to  be  not  uncommon  in  Europe.  In  this 
country  it  is  certainly  rare.  The  attack  begins  abruptly  ;  prodromes  are 
usually  of  short  duration,  or  they  may  be  absent  altogether.  The  tem- 
perature-range is  that  of  the  typical  disease,  save  that  it  in  some  instances 
more  rapidly  attains  its  maximum.  By  the  evening  of  the  third  or  fourth 
day  the  temperature  may  reach  40—40.5°  C.  (104°— 104.9°  F.).  The  in- 
vasion is  often  accompanied  by  rigors,  sometimes  by  a  decided  chill.  In 
some  instances  of  abortive  typhoid  the  absolute  temperature  is  very  high. 
Liebermeister  has  observed  in  such  cases  an  axillary  temperature  of  41.1°  C. 
(106°  F.)  or  even  higher.  There  is  usually  moderate  diarrhoea,  tympany, 
enlargement  of  the  spleen,  sometimes  epistaxis,  and  often  more  or  less 
bronchial  catarrh.  The  characteristic  eruption  is  frequently-  observed, 
and  transient  albuminuria  is  met  with.  Somewhere  between  the  seventh 
and  the  fourteenth  day  "  the  sickness  takes  a  sudden  turn,  and  runs  a 
course  similar,  as  regards  ordinary  enteric  fever,  to  that  which  varioloid 
runs  as  reo-ards  variola  "  (Jaccoud).  Cases  have  been  observed  where  the 
duration  did  not  exceed  five  days  (Griesinger). 

The  defervescence  is  rapid,  often  being  completed  in  from  24  to  72 
hours,  and  is  often  attended  by  profuse  sweating.  Convalescence  is 
rapid.  It  is  in  the  highest  degree  probable  that  in  these  cases  the  intes- 
tinal lesions  undergo  resolution,  their  evolution  being  arrested  short  of 
the  ordinary  necrotic  processes.  We,  therefore,  have  to  do  with  the 
primary  fever  due  to  the  action  of  the  special  poison,  and  not  with  the 
secondary  or  septic  fever  due  to  ulceration  and  the  formation  of  sloughs. 
The  parallelism  between  these  cases  as  compared  with  typical  enteric  fever, 
and  varioloid  as  compared  with  variola,  is  complete. 

The  imperfect  cases  are  to  be  recognized  by  the  occurrence  of  the 
eruption,  enlargement  of  the  spleen,  and  their  occurrence  in  the  same  house 
with,  or  otherwise  in  such  relation  to  well-developed  cases,  as  warrants  the 
supposition  that  they  are  due  to  a  common  infection.  In  100  cases  of 
this  class  Liebermeister  found  that  enlargement  of  the  spleen  occurred  in 
71,  diarrhcea  in  41,  and  roseola  in  21. 

A  still  slighter  disturbance  of  the  functions  of  the  body  may  result 
from  the  infection,  and  give  rise  to  cases  of  abdominal  catarrh  with  eleva- 
tion of  temperature  so  slight  and  so  irregular  that  it  scarcely  deserves  the 
name  of  fever,  38°  C.  (100.  4°   F.).     And  finally,  cases  of  intestinal  ca- 


ENTERIC  OR  TYPHOID  FEVER.  195 

tarrh  occasionally  occur,  in  consequence  of  typhoid  infection,  in  which 
there  is  no  elevation  of  temperature  at  all.  Liebenneister  found  among 
such  cases  many  with  evident  enlargement  of  the  spleen,  and  a  few  with 
an  unmistakable  eruption.  The  action  of  the  bowels  was  irregular;  in 
some  instances  there  was  diarrhcea,  in  others,  obstinate  constipation;  but 
all  the  cases  manifested  a  decided  impairment  of  the  general  health,  lassi- 
tude, depression,  vague  pains,  often  headache  and  loss  of  appetite,  and  a 
furred  tongue.  The  duration  of  an  apparently  trilling  indisposition  was 
particularly  noticeable,  and  he  calls  especial  attention  to  the  fact  that 
there  was  marked  diminution  in  the  frequency  of  the  pulse  without  ap- 
preciable alteration  in  its  character,  and  that  the  pulse  increased  in  fre- 
quency with  convalescence,  before  the  patient  had  quitted  his  bed. 

Dr.  Cayley  states  that  many  cases  and  even  epidemics  of  typhoid  have 
been  met  with  in  which  the  temperature  has  been  subnormal  throughout 
the  whole  course  of  the  disease.  He  cites  the  following  instance  of  such 
an  outbreak,  which  was  observed  by  Dr.  Strube: 

During  the  siege  of  Paris  by  the  Germans  in  1870,  an  epidemic  of  typhoid  fever 
broke  out  among  the  troops,  beginning  to  show  itself  during  the  march  to  Paris,  and 
attaining  its  greatest  height  in  October.  In  November  a  decline  took  place,  which  was 
followed  by  a  fresh  outbreak  in  December.  These  two  outbreaks  differed  greatly  in 
their  characters  ;  the  later  one  resembled  in  all  respects  the  ordinary  form  of  typhoid  ; 
the  earlier  one  presented  very  different  features.  In  many  of  the  cases  the  tempera- 
ture throughout  was  subnormal,  and  in  others  never  exceeded  the  normal  point.  The 
roseola  was  usually  profuse  ;  the  nerve-symptoms  were  of  marked  severity,  and  were 
in  inverse  ratio  to  the  temperature,  consisting  of  violent  delirium  alternating  with 
stupor  ;  the  duration  of  the  fever  was  very  short,  defervescence  usually  taking  place 
at  the  end  of  a  fortnight.  Of  the  twenty-three  fatal  cases,  in  twenty  death  took  place 
during  the  first  fourteen  days.  The  abdominal  symptoms  were  slight,  but  the  charac- 
teristic lesions  were  found  on  post-mortem  examination.  All  the  cases  were  charac- 
terized by  great  prostration.  These  cases  presented  some  features  which  were  probably 
due  to  this  peculiarity  of  the  temperature  :  thus,  the  pulse  was  but  little  accelerated, 
seldom  exceeding  a  hundred  ;  the  tongue  did  not  become  dry  and  brown,  and  the  en- 
largement of  the  spleen  was  either  absent  or  much  less  marked  than  usual.  Dr.  Strube 
attributed  the  peculiar  features  of  this  epidemic  to  the  depressed  condition  of  the 
troops  ;  they  had  been  exposed  to  great  hardships  on  the  way  to  Paris,  over-fatigued 
by  forced  marches,  and  very  insufficiently  supplied  with  food,  and  the  supply  contin- 
ued deficient  for  some  time  after  their  arrival,  owing  to  difficulties  of  transport.  In 
the  later  outbreak  these  conditions  were  no  longer  present. 

Infantile  remittent  fever. — This  term  has  been  applied  to  enteric 
fever  as  it  occurs  in  children,  for  the  reason  that  the  pyrexia  often  assumes 
in  them  a  distinctly  remittent  type  throughout  the  whole  course  of  the 
attack.  The  symptoms  and  complications  are  modified  by  the  age  of  the 
patient.  Children  are  very  susceptible  to  enteric  fever,  and  Murchison 
calls  attention  to  the  fact  that  they  are  often  attacked  in  houses  where 
adults  escape. 


196  THE  CONTINUED  FEVERS. 

In  the  advcDiced  2}^ri<)<h  (\f  life  enteric  fever  runs  a  modified  course. 
Its  onset  is  insidious,  the  febrile  movement  is  less  intense  than  at  earlier 
periods  of  life,  and  during  convalescence  the  temperature  often  falls  to 
markedly  subnormal  ranges.  Tliere  is  especial  danger  of  collapse.  Acute 
delirium  is  not  so  common,  and  diarrhoea  is  less  apt  to  be  urgent.  The 
characteristic  eruption  is  rarely  observed.  Perforation  is  less  frequent  in 
early  and  in  advanced  life  than  in  the  middle  periods.  Murchison  en- 
countered it  twice  in  patients  over  forty,  and  1  saw  it  once  in  the  body  of 
a  gentleman  aged  fifty-three, 

Tijpho-malarial  fever. — This  term,  introduced  by  Dr.  \^^oodward,  has 
been  applied  to  two  essentially  different  conditions:  first,  typhoid  fever 
occurring  either  in  persons  recently  subject  to  malarial  influences,  or  in 
malarious  districts,  and  modified  to  a  greater  or  less  extent  in  its  course 
and  duration  by  malaria.  The  second  is  remittent  fever  in  one  or  another 
of  its  forms,  where  the  symptoms  are  of  grave  character,  and  where, 
sometimes,  in  the  course  of  the  disease,  the  patient  passes  into  that  con- 
dition which  is  called  tlie  "typhoid  state."  The  term  is  an  unfortunate 
one,  and  has  given  rise  to  no  little  confusion  concerning  the  nosological 
position  of  the  various  forms  of  disease  to  which  it  has  been  applied.  It 
is  needless  to  state,  after  what  has  already  been  said  of  the  etiology  of  en- 
teric fever,  that  a  hybrid  disease  to  which  this  term  is  applicable  does  not 
exist. 

Typho-malarial  fever  is  not  a  specific  or  distinct  type  of  disease,  but 
the  term  may  be  conveniently  applied  to  the  compound  forms  of  fever 
which  result  from  the  combined  influences  of  the  causes  of  the  malarious 
fevers  and  of  tj'phoid  fever  (Woodward  '). 

Relapses. 

By  a  relapse  of  enteric  fev'er  is  understood  a  second  evolution  of  the 
specific  febrile  process  after  convalescence  from  the  first  attack  is  fairly 
established  (Murchison).  Relapses  take  place  after  this  disease  with  much 
greater  frequency  than  was  formerly  supposed.  Murchison  observed  them 
in  3  per  cent,  of  2,591  cases  in  the  London  Fever  Hospital;  Griesinger 
in  G  per  cent,  of  463  cases  at  Zurich;  Liebermeister  in  8.6  per  cent,  of 
1,743  cases  at  Basle,  and  other  observers  place  the  frequency  of  their  oc- 
currence at  from  1.4  to  11  per  cent.  This  discrepancy  is  to  be  explained 
in  part  by  the  difference  of  opinion  as  to  what  really  constitutes  a  relapse, 
and  in  part  by  the  fact  that,  among  recent  continental  observers,  the  cold- 
water  treatment  is  generally  employed,  and  relapses  are  much  more  apt  to 
occur  where  the  temperature  is  systematically  kept  down  by  cold  baths 


'  Transactions  of  the  International  Medical  Congress  held  at  Philadelphia  in  1876 : 
Article  Typho-Malarial  Fever. 


ENTERIC    OK    TYPHOID    FEVER 


19; 


than  wliere  the  fever  is  allowed  to  run  its  course  unchecked.  Relapses 
are  to  be  distinguished  from  the  recrudescences  of  fever,  which  are  liaVjle 
to  occur  during-  the  period  of  defervescence,  or  in  the  early  convalescence, 
and  which  last  from  one  to  several  days.  These  recrudescences  may  arise 
from  very  slight  causes,  such  as  errors  of  diet,  solid  food,  mental  emotion, 
or  even  moderate  exertion.  They  are,  in  most  instances,  dependent  upon 
some  local  lesion,  and,  in  particular,  upon  unhealed  intestinal  ulcers. 
Their  occurrence  is  to  be  looked  upon,  then,  as  evidence  of  the  per- 
sistence of  ulceration  and  is  of  no  little  importance  as  determining  the 


iiiiiissnnHiiiniiii 


IDNIGHT  9  "JoAT 


xmKmwnmmfmm 

iliiiinmiiiHBMiiraniw 

■■miiiiiini 


IglliiUHI 


Fia.  Vo. — Relapse  in  Enteric  Fever.     (Irvine.) 


Fig.  17. — Relapse  iu  Knteric  Fever.     (Irvine.) 

treatment  during  convalescence.  They  show  that  the  temperature  remains 
labile,  and  that  the  vaso-motor  system,  to  use  the  words  of  Dr.  Cayley, 
is  still  very  unstable.  This  instability  of  the  vaso-motor  system  in 
enteric  fever  is  shown  by  the  readiness  with  which  the  tache  cerehrale  is 
produced,  and  the  last-named  observer  looks  upon  the  persistence  of  this 
phenomenon  as  a  valuable  guide,  and  as  indicating  that  the  intestinal 
ulcers  have  not  yet  healed,  and  tliat  the  patient  is  therefore  still  liable  to 
the  sequels  of  the  disease. 

True  relapses  are  attended  with  a  fresh  infection  of  the  blood  by  the 


198  THE  CONTINUED  FEVERS. 

specific  cause  of  enteric  fever,  fresh  glandular  infiltration,  enlargement  of 
the  spleen,  and  a  new  eruption  of  rose  spots.  They  are  often  ushered  in 
by  chilliness  or  distinct  rigors,  and  are  attended  by  the  symptoms  com- 
mon in  the  primary  attack. 

After  a  period  of  apyrexia,  varying  from  twenty-four  hours,  or  less, 
to  several  days,  the  relapse  begins  with  a  sudden  rise  in  temperature 
(Figs.  16  and  17).  This  interval  is  marked  by  normal,  or,  as  is  often  the 
case  after  the  defervescence  of  the  acute  febrile  diseases,  subnormal  tem- 
peratures. Of  twenty-nine  relapses  occurring  among  twenty-three  pa- 
tients, and  analyzed  by  the  late  Dr.  Irvine,'  the  average  duration  of  the 
interval  was  a  fraction  over  five  days  ;  in  three  instances  the  duration 
was  over  ten  days,  and  in  four  there  was  no  appreciable  interval,  "  at  least 
no  interval  extending  over  twenty-four  hours."  Periods  of  normal  or 
subnormal  temperature  of  several  hours'  duration  are  common  toward 
the  close  of  enteric  fever;  the  relapse  may  arise  at  the  close  of  such  a 
period  and  be,  so  to  say,  welded  upon  the  primary  attack. 

Da  Costa,^  in  a  valuable  contribution  to  the  knowledge  of  relapses  in 
typhoid,  has  emphasized  the  fact  that  the  prodromic  stage,  so  common 
in  ordinary  attacks,  is  absent.  The  eruption  appears  earlier,  often  upon 
the  fourth  day,  and  is  apt  to  be  coarser  and  redder. 

The  ordinary  complications  of  the  primary  disease  occur  in  relapse, 
just  as  do  its  ordinary  symptoms.  Da  Costa  has  called  attention  to  the 
importance  of  the  transverse  markings  upon  the  nails  in  the  diagnosis  of 
doubtful  relapse  in  cases  that  have  not  come  under  observation  until  after 
the  close  of  the  primary  attack.  The  second  ridge  of  altered  nail-growth 
shows  how  completely  the  nutrition  suffers  during  the  relapse,  and  the 
first  ridge  is  the  visible  sign  of  the  character  of  the  previous  sickness. 

The  following  case  is  extracted  from  Da  Costa's  paper  : 

"A  boy,  thirteen  years  of  age,  was  sent  to  Bed  12  of  my  ward,  December  6,  1876. 
The  history  was  most  unsatisfactory.  He  had  received  a  blow  on  the  back  of  the  head 
about  a  month  before  admission,  and  had  had  a  cough  for  several  months  prior  to  this 
accident.  He  had  been  confined  latterly  to  bed  for  three  weeks  ;  had  bled  from  the 
nose  once ;  and  during  the  first  week  had  had  a  diarrhoea,  which  was  readily  checked 
by  medicine.  The  boy,  though  he  was  stated  to  have  been  delirious  for  a  week,  and 
showed  some  hebetude,  answered  questions  intelligently.  He  complained  of  great 
weakness,  pain  in  the  bowels,  and  tenderness  in  the  muscles  of  the  lower  extremities. 
He  had  sordes  on  the  teeth ;  shallow,  frequent  respiration ;  rales  in  the  chest,  some 
fine;  a  pulse  of  130,  readily  compressible  ;  and  an  evening  temperature  of  10o\  He 
soon  became  extremely  delirious  ;  he  was  very  weak ;  his  feet  were  cold  ;  indeed,  his 
condition  was  so  grave  that  recovery  was  regarded  as  very  doubtful,  and,  notwithstand- 
ing the  obscurity  of  the  symptoms,  wine,  chloric  ether,  and  other  stimulants  were 


'  Relapse  of  Typhoid  Fever,  especially  with  Reference  to  the  Temperature.  By 
J.  Pearson  Irvine,  M.D.,  B.S.,  F.R.C.P.     London,  1880. 

'-'  Remarks  on  Relapses  in  Typhoid  Fever :  Transactions  Philadelphia  College  of 
Physicians.     Third  Series.     Vol.  iii. 


ENTEPwIC    OR   TYPHOID    FEVER.  199 

freely  resorted  to.  Some  of  the  symptoms  and  the  history  pointed  to  a  brain-trouble, 
but  the  case  was  regarded  as  one  of  typhoid  fever ;  and  its  progress,  the  tympany,  the 
occasional  diarrhoea,  the  tenderness  at  the  lower  part  of  the  abdomen,  the  look  of  the 
tongue,  the  course  the  chest-symptoms  took,  and  the  markedly  typhoid  aspect  of 
the  face,  rendered  this  opinion  more  and  more  certain,  although  no  eruption  except 
Budamina  could  be  found.  But  what  gave  us  the  most  information,  and  told  us  that 
we  were  really  dealing  with  a  second  attack,  thus  explaining  the  extraordinary  length 
of  the  malady — a  length  with  difficulty  reconcilable  to  the  view  of  ordinary  typhoid 
fever — was  that  on  the  17th  it  was  noted  that  the  nails  about  half  way  up  showed  a 
white  line  of  impaired  nutrition,  evidently  the  result  of  the  first  attack  of  illness,  and 
that  near  the  root  another  white  line  was  developing,  due  to  the  relapse.  The  patient 
made  a  very  slow  recovery,  and  was  not  free  from  fever  until  the  2tjth.  When  quite 
himself,  we  learned  from  him  that  he  had  had  unmistakable  signs  of  typhoid  fever  for 
several  weeks  before  his  admission ;  that  he  had  been  treated  for  typhoid  fever  by  :i 
physician  ;  and  that  he  was  rapidly  getting  well  when  the  untoward  symptoms  arose 
which  sent  him  to  the  hospital." 

Typhoid  relapse  is  usually  single;  it  is  less  frequently  repeated,  and 
in  rare  instances,  of  which  Irvine  had  the  opportunity  of  studying  five,  a 
third  relapse  takes  place. 

The  patient  whose  temperature  is  represented  in  the  accompanying  chart  was  a 
male,  aged  twenty-four,  and  was  under  the  care  of  Dr.  Pollock,  in  Charing  Cross  Hos- 
pital. He  was  admitted  in  October,  1877,  and  eight  days  afterward  his  primary  attack 
of  typhoid,  which  had  lasted  four  weeks,  seemed  to  be  at  an  end.  The  temperature 
became  subnormal,  but  did  not  remain  so,  for  within  twenty-four  hours  it  rose  suddenly 
and  quickly,  and,  by  the  third  afternoon  of  what  proved  to  be  relapse,  was  104.6^  Fahr. 
It  had  risen  from  97°  Fahr. — nearly  eight  degrees — without  remission.  The  pulse  was 
never  above  120,  and  usually  about  lOU  ;  the  bowels  were  constipated.  There  was  a 
remission  of  the  temperature  on  the  fifth  morning,  but  on  the  fifth  evening  it  was 
again  104. G°  Fahr.,  and  it  fluctuated  for  the  next  five  days  between  104°  Fahr.  and 
103°  Fahr. ,  with  a  slight  tendency  to  daily  defervescence.  It  did  not  fall  on  the  eighth 
and  ninth  days,  as  in  more  favorable  cases,  and  on  the  tenth  evening  was  as  high  as 
104.7°  Fahr.  The  patient  during  these  days  was  ill  as  he  could  be  ;  he  had  a  weak 
and  frequent  pulse,  was  troubled  with  vomiting,  and  was  only  kept  alive  by  stimulants. 
He  passed  two  or  three  typhoid  stools  daily,  and  had  a  typhoid  eruption.  One  could 
not  but  contrast  this  dangerous  case  with  others  of  favorable  omen,  in  which  the  tem- 
perature fell  at  the  very  time  when  here  it  remained  persistently  high.  On  the 
twelfth  evening  the  temperature  had  a  favorable  fall,  and  on  the  morning  of  the  four- 
teenth day  was  only  101'  Fahr.  For  the  two  following  days  it  exacerbated,  but  on 
the  sixteenth  evening  fell  decidedly,  and  gradually  descended  to  subnormal  on  the 
twenty-first  day  of  relapse.  On  the  sixteenth  day  the  patient  was  exceedingly  low, 
and  his  stimulants  were  increased,  with  the  best  results.  Constipation  was  marked 
at  this  time,  and  simple  enemata  were  given.  On  the  twenty-first  day  convalescence 
began,  and  for  about  seven  days  temperature  was  subnormal.  Then  came  a  second 
relapse.  During  the  apyrexial  interval  constipation  persisted.  Relapse  set  in  suddenly, 
and  the  only  warning  was  given  by  the  thermometer.  On  the  first  day  temperature 
was  98°  Fahr.,  and  on  the  fifth  day  104°  Fahr.  The  patient  looked  ill,  but  not  seri- 
ously ill.  He  had  no  diarrhoea;  on  the  contrary,  constipation  was  still  obstinate. 
From  the  fifth  to  the  seventh  the  temperature  fell  decidedly,  and  on  the  morning  of 
the  seventh  day  was  only  100.3    Fahr.     But   the  evening  temperature  remained  high 


200 


THE    CONTINUED    FEVEKS. 


to  the  tenth  day  (103.6°  Fahr. },  and  the  patient,  judging  from  general  symptoma,  was 
not  free  Irom  danger.  On  ihe  tenth  evening  a  "  critical"  fall  began,  and  went  on  to 
the  following  morning,  when  the  temperature  was  but  98  Fahr.,  a  fall  of  nearly  six 
degrees  having  occurred  in  less  than  twelve  hours.  A  slight  rise  followed,  but  only  to 
101  Fahr.,  and  day  by  day  the  temperature  fell,  and  became  subnormal  on  the  eigh- 
teenth day  of  relapse.  For  the  succeeding  eight  days  convalescence  seemed  established, 
and  the  patient  craved  for  food,  the  temperature  contmuing  subnormal  and  constipa- 
tion being  decided.  Then  came  a  tidrd  rdapse.  as  well-marked  as  its  predecessors, 
for  from  97.4  Fahr.  on  the  first  day  of  relapse  the  temperature  rose  with  little  remis- 
sion to  103.8^  Fahr.  on  the  fifth  day — that  is,  nearly  six  and  a  half  degrees.  It  may 
be  said  in  this  relapse  that  from  the   fifth  morning  there  was  a  distinct  downward 


Fig.  is. — Multiple  Relapee  in  Enteric  Fever.     (Irvine.) 


;    C.  tF    ■~T",    .    - 

j/'^f -•-- r-t— r— I— 

-        \10?_    ^      W    i\;    .        ■   ■ 


\j6li9r 


'm;mmh. 


Continuation  of  Y'va-  IS. 


tendency  to  the  end  of  the  attack,  but  the  relapse  had  a  marked  similarity  with  the 
first  and  second,  and  with  those  met  with  in  other  cases.  As  in  many  favorable  in- 
stances, there  was  no  tendency,  at  any  hour  from  the  fifth  to  the  tenth  day,  to  the  ele- 
vation of  temperature  reached  on  the  fifth  day.  and  the  patient  day  by  day  seemed  to 
improve,  the  general  symptoms  being  comparatively  insignificant.  On  the  ninth  morn- 
ing there  was  a  considerable  fall  to  99"  Fahr..  and  though  the  temperature  on  the 
same  evening  rose  to  103  3' Fahr..  the  daily  fall  afterward  showed  permanent  ten- 
dencies. The  third  stage  of  the  relapse  began,  but  cut  short ;  from  the  tenth  day 
the  temperature  went  down,  and  on  the  fourici'iitk  day  became  subnormal,  where  it 
remained  for  many  days,  during  whioh  an  uninterrupted  convalescence  was  entered 
upon. 


ENTERIC  OR  TYPHOID  FEVER.  201 

The  relapse  deciaies  itself  by  an  unexpected  and  prolonged  rise  in 
temperature.  Sometimes  the  rise  is  almost  continuous  ;  at  others,  morn- 
ing remissions  occur,  but  usually  the  maximum  is  attained  on  the  fifth 
evening.  The  fever  remains  subcontinuous  until  the  eighth  or  ninth  day, 
when  a  marked  and  critical  fall  takes  place.  This  fall,  in  the  absence 
of  hemorrhages  or  other  accidents,  is  of  favorable  prognostic  significance; 
but  it  indicates  the  end  of  the  primary  fever  of  the  relapse,  not  the  end 
of  the  relapse.  Upon  the  tenth  day  a  decided  rise  takes  place,  the  fever 
almost  reaching  its  previous  height,  but  from  this  time  the  morning  re- 
missions are  marked. 

The  duration  of  the  relapse  is  usually,  but  not  invariably  shorter  than 
that  of  the  primary  attack.  Of  fifty-three  cases  noted  by  Murchison,  the 
mean  duration  of  the  first  attack  was  26.58  days,  of  the  interval,  11.27 
days,  and  of  the  relapse  15  days  ;  while  the  mean  total  duration  of  the 
sickness  was  52.86  days.  Dr.  Cayley  mentions  a  case  in  which  the  tem- 
perature was  maintained  at  febrile  heights,  without  distinct  remissions, 
for  eighty  days.  As  a  rule,  the  relapse  is  milder  than  the  primary  attack, 
but  exceptions  occur.  In  one-third  of  Murchison's  cases  the  relapse  was 
more  severe  than  the  first  attack,  and  of  the  fifty-three  cases,  seven  died. 

There  is  danger  of  the  patient's  dying  of  exhaustion  when  the  illness 
is  protracted  by  relapse  or  repeated  relapses;  but  death  may  occur  in  con- 
sequence of  any  of  the  events  which  bring  it  about  in  ordinary  attacks. 
Thus,  Irvine  records  a  case  in  which  death  suddenly  took  place  on  the 
fifteenth  morning  of  relapse,  in  consequence  of  failure  of  the  heart  ;  an- 
other, where  it  occurred  on  the  twenty-fifth  day  of  relapse,  and  there  was 
found  post-mortem,  suppuration  of  mesenteric  glands,  and  recent  general 
peritonitis,  without  perforation;  and  a  third  in  which  the  temperature  fell 
upon  the  twenty-eighth  day  of  the  illness  to  98°  F.,  but  rose  again  and 
the  patient  died  upon  the  thirty-eighth  day  ;  the  necropsy  revealed  per- 
foration and  general  peritonitis.  Da  Costa  mentions  a  case  in  which  a 
second  relapse  was  much  protracted  by  intense  pulmonary  congestion, 
and  in  which  several  violent  intestinal  hemorrhages  happened  after  the 
sixty-sixth  day  of  the  original  seizure.     Fortunately,  recovery  took  place. 

Post-mortem  examination  of  the  bodies  of  those  who  have  died  in 
the  relapse  of  enteric  fever  discloses  the  lesions  of  the  primary  disease. 
The  individual  intestinal  lesions  are  less  numerous,  for  the  reason  that 
only  those  glands  and  patches  of  Peyer  are  involved  that  escaped  during 
the  first  attack.  The  ulceration  is,  therefore,  higher  up  in  the  ileum,  and 
co-exists  with  the  recent  cicatrices  of  the  former  attack,  which  are  most 
numerous  and  most  extensive  near  the  ileo-caecal  valve. 

The  cause  of  relapse  in  enteric  fever  is  involved  in  no  little  obscurity. 
It  is  certain  that  it  is  in  no  case  to  be  attributed  to  errors  in  diet,  over- 
exertion, or  any  other  non-specific  cause.  It  is  here  that  the  distinction 
between  recrudescences  and  relapses  becomes  practically  most  important. 


202  THE  CONTINUED  FEVERS. 

Unfavorable  non-specific  influences  constantly  cause  recrudescences  ;  they 
never  cause  relapse.  The  latter  is  due  to  reinfection  by  the  specific  cause 
of  the  disease  ;  it  is,  in  fact,  a  repetition  of  the  primary  attack.  It  is 
held  by  many  observers  that  the  second  infection  takes  place  from  the 
source  of  the  original  poison.  When  relapses  occur  in  patients  who  have 
been  removed  to  hospital  early  in  the  attack,  this  explanation  is  in- 
adequate. It  is  most  probable  that  relapse  is  due  to  resorption  of  the 
poison  from  the  lymph-follicles  of  the  ileum  and  from  the  mesenteric 
glands.  Some  portion  of  the  poison  does  not  undergo  those  changes  in 
the  body,  which  are  necessary  to  its  destruction  or  elimination,  until  a 
later  period  than  that  to  which  the  primary  attack  is  due.  In  a  majority 
of  instances  the  patients,  being  protected  by  the  illness  just  passed 
through,  do  not  suffer  ;  exceptionally  they  are  not  protected,  and  the  re- 
lapse occurs.  Relapse  is  certainly  not  more  common  than  second  at- 
tacks of  enteric  fever,  due  to  an  independent  infection  at  a  remote 
period. 

Anatomical  Lesions. 

Enteric  fever  differs  from  the  other  continued  fevers,  -with  the  excep- 
tion of  cerebro-spinal  fever,  in  the  invariable  presence  of  specific  anatomi- 
cal lesions.  These  lesions  are  so  characteristic  that  an  examination  of 
the  body  after  death  will  in  all  cases  make  known  the  nature  of  the  dis- 
ease, even  when  the  symptoms  have  been  obscure  or  are  unknown.  It  is 
important,  however,  to  bear  in  mind  that  the  lesions  of  the  intestines  and 
of  the  mesenteric  glands  do  not  constitute  the  disease,  but  that  the  poi- 
son, which  is  its  specific  cause,  is  taken  up  by  the  fluids  of  the  body,  and 
gives  rise  to  general  disturbances,  which  are  an  essential  element  of  all 
fully  developed  cases,  and  that  this  constitutional  disturbance  manifests 
itself  at  a  very  early  period  in  the  disease.  The  more  important  symp- 
toms of  enteric  fever  are  directly  attributable  to  the  general  disease,  and 
not  to  the  special  lesions.  The  lesions,  therefore,  fall  naturally  into  two 
groups.  The  first  embraces  those  arising  from  the  local  action  of  the 
specific  poison,  and  includes  changes  in  the  lymphatic  system  of  the  in- 
testinal canal.  These  changes  consist  of  an  intense  inflammation,  with 
new-growth,  producing  an  increase  in  the  size  of  the  lymph-follicles 
which  constitute  Peyer's  patches  and  the  solitary  glands,  and  subsequent 
necrotic  processes  resulting  in  the  partial  destruction  of  these  tissues. 
Secondary  changes  in  the  mesenteric  glands,  and  enlargement  of  the 
spleen,  are  also  to  be  referred  to  this  group.  These  are  the  lesions  which 
are  to  be  regarded  as  characteristic  of  enteric  fever.  They  are  present  in 
the  mild  and  abortive,  as  well  as  in  the  fully  developed  cases. 

The  second  group  includes  lesions  which  are  not  the  direct  result  of 
the  local  action  of  the  special  poison,  but  are  due  to  the  constitutional 


ENTERIC  OR  TYPHOID  FEVER.  203 

infection.  They  consist  of  degenerative  changes  involving  the  tissues  of 
various  organs,  and  are  to  be  found  generally  manifested  throughout  the 
body,  and  particularly  in  the  liver,  the  kidneys,  the  voluntary  muscles, 
the  heart,  the  salivary  glands,  and  the  pancreas.  Analogous  changes 
probably  take  place  in  the  structure  of  the  nervous  system,  particularly 
the  brain.  These  changes  are  not  peculiar  to  enteric  fever  ;  they  occur 
in  other  acute  febrile  diseases,  and  are  dependent  upon  the  intensity  and 
duration  of  the  pyrexia.  They  attain  their  fullest  development,  hovp- 
ever,  in  enteric  fever  for  the  reason  that  this  disease  is  characterized  by 
an  unusually  long  continuance  of  the  febrile  movement. 

Cadaveric  rigidity  is  usually  marked  and  of  long  duration.  Emaci- 
ation is  often  extreme.  The  integuments  of  the  dependent  part  of  the 
body  are  apt  to  be  more  or  less  discolored,  but  the  deep  livid  discolora- 
tion of  typhus  is  rare.  Except  where  death  has  taken  place  in  conse- 
quence of  pulmonary  complications,  the  face  is  not  often  livid.  The  char- 
acteristic rash  of  enteric  fever  is  never  observed  on  the  dead  body,  even 
in  those  cases  where  the  spots  have  been  numerous  immediately  before 
death.     Sudamina,  and  other  accidental  eruptions,  persist. 

TJie  digestive  tract. — The  pharyngeal  mucous  membrane  is  in  most  in- 
stances healthy,  but  it  occasionally  exhibits  signs  of  recent  inflammation, 
and  sometimes  distinct  points  of  ulceration.  The  most  common  seat  of 
the  ulcers  is  at  the  lower  part  of  the  pharynx.  They  are  usually  superfi- 
cial, but  may  extend  to  the  muscular  coat.  The  pharyngeal  mucous 
membrane  may  be  the  seat  of  a  diphtheritic  exudation.  Occasionally 
the  oesophagus  shows  the  evidences  of  ulcerative  processes  similar  to 
those  met  with  in  the  pharynx. 

When  present  in  the  oesophagus,  the  ulcers  are  most  numerous  at  the 
lower  or  cardiac  extremity  of  this  viscus,  and  vary  from  simple  excoria- 
tions to  deep  lesions  implicating  the  muscular  coat.  The  foregoing 
changes  are  never  found  when  death  occurs  earlier  than  the  third  week 
of  the  disease.  They  are  not  met  with  after  death  from  typhus,  or  other 
acute  diseases,  but  are  not  on  this  account  to  be  regarded  as  analogous 
to  the  specific  lesions  of  the  intestine  (Murchison). 

The  stomach  presents  no  changes  peculiar  to  this  disease,  and  is  in 
many  cases  healthy.  It  occasionally  is  the  seat  of  morbid  appearances 
consisting  of  hyperasmia,  softening  and  superficial  erosions  of  the  mucous 
membrane. 

The  duodenxmi  usually  presents  no  anatomical  changes.  Sometimes 
it  exhibits  the  evidences  of  increased  vascularity,  or  some  enlargement 
of  the  mucous  follicles.     Ulceration  does  not  occur. 

The  small  intestine  is  mostly  healthy  at  its  upper  part;  it  does  not,  as 
a  rule,  contain  much  gas.  The  Jejiimim  and  the  upper  part  of  the  ileum 
may  be  moderately  distended,  the  lower  portion  of  the  ileum  is  commonly 
collapsed.      If  peritonitis  has  preceded  death,  the  intestines  are  commonly 


204  THE  CONTINUED  FEVERS. 

more  or  less  distended.  The  tympany  which  belongs  to  the  disease  is 
due  to  the  presence  of  gas  in  the  colon.  Invagination  of  the  intestine, 
unaccompanied  by  the  evidences  of  inflannnation,  is  occasionally  met 
with  at  one  oi  more  points.  This  is  probably  due,  as  Murchison  sug- 
gests, to  the  death-struggle,  and  is  found  after  other  diseases,  in  which 
death  is  preceded  by  a  high  degree  of  torpor  of  the  cerebro-spinal  sys- 
tem. Round  or  tape-worms  are  occasionally  voided  during  enteric  fever, 
and  are  sometimes  also  found  in  the  intestines  after  death.  Small  masses 
of  fecal  matter  of  an  ochrous  yellow  color,  intestinal  mucus,  sloughs,  and, 
if  there  have  been  intestinal  hemorrhage  during  life,  more  or  less  blood 
are  met  with  in  the  irttestines.  The  mucous  membrane  of  the  ileum  is 
usually  hyperaimic;  this  redness  may  be  uniformly  distributed,  or  it  may 
occur  in  patches.  It  is  most  intense  in  the  neighborhood  of  the  ulcerated 
glands,  and  in  particular  in  the  region  of  the  ileo-cjecal  valve.  When 
death  takes  place  in  the  later  stages  of  the  disease,  the  mucous  mem- 
brane of  the  ileum  often  presents  a  grayish  appearance.  It  is  frequently 
softened  in  consequence  of  post-mortem  changes. 

The  foregoing  lesions  are  not  peculiar  to  enteric  fever,  nor  are  they 
constant  in  it. 

Those  which  are  about  to  be  described,  and  which  involve  the  agmi- 
nate and  solitary  glands  of  the  ileum,  are  characteristic  of  enteric  fever, 
and  are  constantly  met  with  in  the  bodies  of  those  who  have  died  of  that 
disease.  They  constitute  the  specific  or  primary  local  lesions,  and  pre- 
sent different  appearances,  according  to  the  period  of  the  illness  in  which 
death  has  taken  place.  The  progress  of  the  pathological  processes  which 
result  in  these  lesions,  may  be  divided  into  four  periods,  namely:  the  stage 
of  medullary  infiltration,  the  stage  of  softening  and  necrosis,  the  stage  of 
ulceration,  and  the  stage  of  cicatrization.  Two  or  more  of  these  stages  are 
often  represented  by  the  lesions  found  in  the  same  body,  as  the  morbid 
process  always  commences  at  the  lower  extremity  of  the  ileum,  near  the 
ileo-crecal  valve,  and  at  a  later  period  involves  the  patches  higher  up. 
The  periods  occupied  by  these  stasres  usually  consist,  in  severe  uncom- 
plicated cases,  of  about  a  week  each,  but,  as  with  the  periods  of  the  febrile 
movement,  we  must  reckon  sometimes  four  or  five  days  to  each,  some- 
times as  many  as  eight  or  nine. 

The  first  stage. — The  mucous  membrane  of  the  intestine,  particularly 
that  surrounding  Peyer's  patches  in  the  lower  part  of  the  ileum,  is  hyper- 
fpmic  and  swollen.  The  agminate  and  solitary  glands  are  infiltrated  by 
an  excessive  proliferation  of  cellular  elements;  the  follicles  are  swollen 
and  distended.  The  neighboring  mucous  membrane  is  also  infiltrated 
with  cells.  This  change  has  been  observed  in  cases  where  death  has 
taken  place  as  early  as  the  second  day.  The  Peyer's  patches  are  thick- 
ened, hardened,  and  elevated  from  half  a  line  to  two  lines  above  the  sur- 
rounding: mucous  membrane.      Their  surface  is   usuallv  uneven  and  of  a 


ENTERIC  OK  TYPHOID  FEVEU.  205 

reddish  or  a  reddish  gray  color.  Tlie  number  implicated  is  very  variable; 
sometimes  it  does  not  exceed  three  or  four,  at  other  times  more  or  less 
infiltration  is  to  be  observed  in  nearly  all  the  patches.  As  the  long  axis 
of  Peyer's  patches  corresponds  to  that  of  the  intestine,  it  follows  tliat, 
wiiere  a  number  of  adjoining  patches  are  infiltrated,  very  extensive  linear 
lesions  sometimes  result  from  their  confluence.  The  solitary  glands  in 
the  neighborhood  of  the  diseased  patches  are  commonly  involved  in  a 
similar,  process.  Usually  a  comparatively  small  number  of  them  are  im- 
plicated, but  in  exceptional  cases  the  solitary  glands  principally  are  dis- 
eased, and  very  rarely  there  is  disease  of  the  solitary  follicles  without 
any  implication  whatever  of  the  Peyer's  patches.  The  solitary  follicles 
of  the  large  intestine,  especially  those  in  the  neighborhood  of  the  ileo- 
ca.^cal  valve,  are  likewise  involved,  and  they  sometimes  form,  by  the  ex- 
tension of  the  infiltration  to  the  neighboring  mucous  membrane,  patclies 
of  considerable  size. 

The  second  stage. — The  hyperemia  of  the  mucous  membrane  now  de- 
creases, but  the  infiltration  of  the  solitary  and  agminate  glands  goes  on. 
Some  of  the  swollen  patches  undergo  partial  or  complete  necrosis,  which 
may  be  superficial,  or  may  proceed  to  various  depths,  implicating  the 
muscular  or  even  the  serous  coat  of  the  intestine.  This  process  is  usu- 
ally nearly  completed  by  the  end  of  the  second  week,  and  at  this  time, 
or  in  abortive  cases  even  earlier,  reparative  processes  begin,  and  the 
affected  patches  that  have  not  been  the  seat  of  sloughing,  undergo  reso- 
lution. The  sloughs  are  of  a  yellowish  brown  or  greenish  color,  from 
staining  with  the  intestinal  contents,  and  particularly  the  bile;  some- 
times, being  infiltrated  with  blood,  they  are  dark  in  color. 

The  tldrd  stage. — The  sloughs  are  now  gradually  detached.  Ulcers 
of  varying  depth  and  of  a  size  and  form  corresponding  to  the  area  of  the 
necrosed  tissue,  are  formed.  If  an  entire  patch  be  involved,  the  ulcer 
is  elliptical,  and  of  considerable  size.  Ulcers  resulting  from  necrosis  of 
infiltrated  solitary  glands  are  usually  small  and  round.  They  may,  how- 
ever, enlarge  by  secondary  implication  of  the  surrounding  tissue.  The 
edges  of  the  intestinal  ulcers  are  usually  abrupt,  the  surrounding  tissue 
being  thickened  and  overhanging.  At  the  close  of  the  third  stage  the 
sloughs  are  for  the  most  part  detached. 

The  fourth  stage  is  that  of  cicatrization.  The  swelling  at  the  edges 
of  the  ulcers  gradually  diminishes,  and  the  surface  becomes  covered  with 
a  delicate  layer  of  granulations,  which  is  transformed  into  connective 
tissue,  and  ultimately  covered  with  epithelium.  Where  the  ulceration 
has  extended  into  the  muscular  coat,  neither  the  mucous  membrane  nor 
the  villi,  according  to  Hoffmann,'  are  reproduced. 

The  cicatricial  surface-tissue  is  at  first  adherent  to  the  underlying  coat. 

'  Ziemssen's  Encyclopaidia  of  Medicine  :  Liebermeister's  article  on  Typhoid  Fever. 


206  THE  CONTINUED  FEVEKS. 

It  usually  becomes,  after  a  time,  movable,  and  may,  if  the  ulceration  have 
been  superficial,  even  be  coated  with  villi.  The  inland-structure  is,  how- 
ever, not  regenerated.  The  resulting  scar  is  slightly  depressed,  firm, 
smoother  and  less  vascular  than  the  surrounding  mucous  membrane.  It 
is  never  surrounded  by  puckering,  and  never  gives  rise  to  diminution  in 
the  calibre  of  the  bowel.  Where  cicatrization  takes  place  in  this  simple 
way,  the  time  required  to  heal  each  single  ulcer  is  probably  about  a  fort- 
night. Not  infrequently  the  process  of  healing  is  much  more  complex. 
While  one  part  of  the  ulcer  is  undergoing  cicatrization,  the  sloughing  in 
another  part  may  continue,  so  that  the  ulcer  may  be  said  to  have  become 
serpiginous.  Such  ulcers  often  persist  for  a  long  time,  prolonging  con- 
valescence, and  occasionally  causing  death  by  perforation  at  a  compar- 
atively remote  period  from  the  commencement  of  the  attack.  The  scars 
are  often  more  or  less  strongly  pigmented. 

Not  all  the  patches  necessarily  slough.  In  a  certain  proportion  of 
them  the  morbid  processes  are  arrested  prior  to  the  stage  of  necrosis,  and 
in  the  abortive  cases,  it  is  probable  that  all  the  patches  of  infiltration  un- 
dergo resolution,  without  sloughing,  the  swelling  gradually  diminishing 
until  the  patches  and  follicles  at  length  resume  their  normal  condition. 

The  thickening  of  the  patches  is  due  not  only  to  the  infiltration  of  the 
follicles,  but  also  to  an  increase  in  the  interstitial  connective  tissue.  If, 
in  the  period  of  resorption,  the  follicles  undergo  resolution  more  rapidly 
than  the  interstitial  net- work,  a  reticulated  surface  remains;  or  the  folli- 
cles may  break  down  and  be  discharged,  while  the  hypertrophied  con- 
nective tissue  remains  unaffected,  thus  giving  rise  to  a  similar  reticulated 
surface.  At  the  same  time,  numerous  minute  points  of  pigmentation  are 
formed  in  the  seat  of  the  softened  follicles,  and  these  persist,  presenting  a 
peculiar  appearance  which  has  been  thought  to  resemble  that  of  the 
newly  shaven  beard.  This  appearance  is  not  characteristic  of  enteric 
fever,  as  was  formerly  thought.  It  is  met  with  after  death  from  other 
diseases,  and  in  the  bodies  of  those  who  have  never  been  the  subjects  of 
enteric  fever. 

Analogous  changes  take  place  at  the  same  time  in  the  mesenteric 
glands.  These  bodies  become  more  or  less  swollen  in  consequence  of 
cellular  hyperplasia  and  increase  of  their  connective  tissue.  The  enlarge- 
ment of  the  glands  is  greatest  in  those  portions  of  the  mesentery  which 
correspond  to  the  diseased  portions  of  intestine.  In  some  cases  all  the 
mesenteric  glands  are  more  or  less  swollen.  The  swollen  glands  are 
hyperjemic,  bluish,  and  tense.  They  may  attain  the  size  of  a  small  bean 
or  chestnut;  sometimes  they  are  as  large  as  a  pullet's  egg.  Later  in  the 
course  of  the  disease  they  become  pale,  gray,  or  reddish  gray.  After  the 
detachment  of  the  sloughs  from  the  intestinal  ulcers,  the  enlarged  mesen- 
teric glands  shrink,  and  gradually  regain  their  normal  appearance.  Some 
of  them,  however,  may  undergo  partial  softening.     If  this  be  not  exten- 


ENTERIC  OR  TYPHOID  FEVER.  207 

sive,  complete  resolution  may  ultimately  occur;  if,  however,  the  soften- 
ing be  considerable,  resorption  does  not  take  place,  but  the  softening  ma- 
terial undergoes  cheesy  metamorphosis  and  ultimately  becomes  calca- 
reous. Sometimes,  however,  the  softening  results  in  the  formation  of 
pseudo-abscesses,  which  may  burst  into  the  peritoneal  cavity  and  give 
rise  to  general  peritonitis. 

Other  lymphatic  glands,  particularly  those  in  the  fissure  of  the  liver, 
the  retro-peritoneal,  and  the  bronchial  glands,  are  occasionally  found  en- 
larged. The  lymphatic  follicles  at  the  root  of  the  tongue  and  in  the  ton- 
sils undergo  changes  analogous  to  those  just  described,  giving  rise  to 
enlargements  which  appear  early  in  the  course  of  the  disease,  and  usually 
disappear  without  further  change;  although  in  some  cases  softening,  rup- 
ture, and  subsequent  ulceration  result. 

The  changes  in  the  spleen  are  to  be  regarded  as  analogous  to  the 
changes  which  take  place  in  the  lymph-follicles  of  the  intestine  and  in 
the  mesenteric  glands.  The  spleen  is  tense  and  hyperajmic.  On  section, 
it  is  of  a  brownish  red  color;  in  the  early  periods  of  the  disease  it  is  of 
moderate  consistence  ;  later  its  tissue  is  soft,  pulpy,  or  even  diffluent. 
The  enlargement  is  almost  always  present  when  death  occurs  before  the 
thirtieth  day.  At  a  later  period  the  capsule  is  wrinkled,  the  tissue  firmer, 
the  stroma  more  prominent,  and  the  color  paler.  Hemorrhagic  infarctions 
are  often  met  with.  The  enlarged  and  softened  spleen  of  the  later  stages 
of  typhoid  fever  is  liable  to  be  ruptured  by  mechanical  force,  as  in  the 
instance  referred  to  by  Bartholow,  and  in  some  instances  it  is  said  to  have 
undergone  spontaneous  rupture.  In  a  small  proportion  of  the  cases  en- 
largement of  the  spleen  does  not  take  place.  This  is  more  frequent  in 
elderly  persons  than  in  the  young.  Sometimes  thickening  of  the  cap- 
sule has  apparently  prevented  the  occurrence  of  the  enlargement,  and  in 
other  instances  it  has  been  thought  that  the  spleen  was  abnormally  small 
before  the  occurrence  of  the  disease. 

Gerhardt '  states  that,  in  many  cases  in  which  a  relapse  takes  place,  the 
enlarged  spleen  is  not  diminished  during  the  non-febrile  interval  between 
the  original  attack  and  the  relapse. 

The  second  group  of  anatomical  changes  comprises,  as  has  been  said, 
parenchymatous  degenerations  of  the  various  organs  of  the  body.  These 
changes  are  the  result  of  the  long  duration  of  the  febrile  movement. 
They  are  therefore  not  confined  to  typhoid  fever,  nor  are  they  character- 
istic of  it. 

The  liver  is  occasionally  hyperasmic,  but  in  most  cases  it  is  normal  in 
appearance,  or  it  may  be  pale.  In  many  cases  it  is  softened,  and  upon 
microscopical  examination  the  cells  are  found  to  be  granular,  loaded  with 
fat,  the  nuclei  indistinct,  or  no  longer  to  be  seen.     These  microscopical 

'  See  Leibermeister's  article  on  Typhoid  Fever,  in  Ziemssen's  Cyclopaedia. 


208  THE    CONTINUKD    FP:VERS. 

appearances  are  soinetiincs  observed  where  the  organ  does  not  appear  to 
be  softer  than  normal.  The  changes  in  the  liver-cells  are  proportionate 
to  the  intensity  and  duration  of  the  febrile  movement.  In  eases  where 
this  has  been  slight  these  changes  are  little  marked,  or  even  wholly  ab- 
sent. The  amount  of  bile  is  usually  markedly  diminished,  and  in  the 
later  periods  of  the  disease  it  is  thin  and  almost  colorless. 

71ic  Jkkhieys  also  show  parenchymatous  degeneration.  The  epithe- 
lium is  granular,  the  contour  of  the  cells  indistinct,  and  the  nuclei  dis- 
appear. These  changes  affect  first  the  cortex,  later  the  pyramids.  In 
many  cases  they  are  but  little  marked.  They  are  usually  associated 
with  albuminuria,  although  Liebermeister  states  that  he  has  repeatedly 
noted  absence  of  albuminuria  throughout  the  whole  course  of  the  disease, 
where  at  the  autopsy  advanced  degeneration  of  the  kidneys  was  dis- 
covered. 

Softening  of  the  muscular  tissue  of  the  heart  is  very  common.  This 
softening  is  due  to  the  parenchymatous  degeneration  which  occurs  in  the 
severer  cases  of  the  disease,  and  is,  like  similar  changes  in  other  organs, 
proportionate  to  the  intensity  and  duration  of  the  febrile  movements. 
In  its  higher  degrees  the  degeneration  gives  rise  to  changes  in  the  mus- 
cular tissue  that  are  easily  recognizable.  The  heart  is  soft  and  of  a  pale, 
gray,  yellowish  or  "  faded-leaf  "  color,  the  muscular  tissue  is  easily  torn, 
and  the  organ  thrown  upon  the  table  settles  down  into  a  formless  mass. 
The  changes  consist  in  the  deposit  in  the  muscular  tissue  of  numerous 
minute  granules,  which  are  often  arranged  in  long  rows.  If  they  be 
slight,  the  striations  are  still  visible;  but  in  the  higher  grades  the  muscu- 
lar fibres  are  filled  with  granules,  and  the  striations  disappear  altogether. 
The  waxy  change  referred  to  farther  on  is  less  frequent  in  the  heart  than 
in  the  voluntary  muscles.  The  feebleness  of  the  heart,  which  is  charac- 
teristic of  typhoid  fever,  and  particularly  of  the  advanced  stages  of  severe 
cases,  is  proportionate  to  the  degree  of  degeneration  found  after  death. 

Evidences  of  recent  endocarditis  with  thickening  of  the  aortic  or 
mitral  valves,  are  sometimes  met  with.  The  pericardium  is  usually  healthy. 
Recent  pericarditis  belongs  to  the  rarest  of  the  anatomical  changes  ob- 
served after  death  in  enteric  fever. 

Fatty  degeneration  of  tlie  minute  arteries  of  the  brain,  kidneys  and 
other  organs  was  demonstrated  by  Hoffmann,  who  also  called  attention 
to  the  frequency  with  which  thickening  and  opacity  of  the  inner  coat  of 
the  larger  vessels,  and  particularly  of  the  pulmonary  arteries,  occur. 

The  blood  is  dark-colored,  with  small,  soft  coagula.  Pale,  fibrinous 
clots  are  frequently  found  in  the  heart.  If  death  takes  place  in  the  latest 
stage  of  the  disease,  or  during  convalescence,  the  vessels  are  often  nearly 
empty,  the  blood  thin  and  watery,  and  the  tissues  (rdematous. 

Cha/if/es  in  tlie  voluntary  muscles,  similar  to  those  already  described 
as  occurring  in  the  muscular  tissue  of  the  heart,  are  of  very  frequent  oc- 


ENTERIC  OR  TYPHOID  FEVER.  209 

currence  in  enteric  fever.  They  were  first  described  by  Zenker,'  who  dis- 
tinguishes two  forms.  The  first  is  a  granular  degeneration,  which  in 
its  highest  degree  does  not  differ  from  ordinary  fatty  degeneration. 
Less  fully  developed,  it  consists  in  the  appearance  in  the  fibres  of  minute 
granules,  tending  to  form  themselves  into  rows  and  obscuring  the 
striations.  The  second  form  is  a  waxy  degeneration,  by  which  the  mus- 
cle-substance is  converted  into  a  glistening,  colorless  mass,  in  which  the 
striations  are  no  longer  to  be  seen.  The  granular  degeneration  is  more 
frequent,  but  the  two  forms  are  often  associated,  sometimes  one,  sometimes 
the  other  predominating.  These  changes  are  not  peculiar  to  typhoid 
fever,  but  occur  in  other  severe  febrile  diseases,  and  are  probably  in  all 
cases  the  result  of  the  long-continued  high  temperature.  They  are  most 
marked,  usually  in  the  second,  third,  and  fourth  weeks.  If  death  takes 
place  at  a  later  period,  the  degeneration  of  the  muscles  disappears,  or  is 
only  to  be  observed  in  its  results,  namely,  softening,  hemorrhages,  and 
pseudo-abscesses  in  the  substance  of  the  muscular  masses.  The  rectus 
abdominalis,  the  adductors  of  the  thigh,  the  pectorales  major  and  minor, 
the  diaphragm  and  the  tongue  are  more  frequently  implicated  in  these 
changes,  though  all  the  voluntary  muscles  share  in  them  to  some  extent. 
The  excessive  loss  of  power,  which  appears  both  at  the  height  of  the  dis- 
ease and  during  convalescence,  is  due  in  part  to  impairment  of  the  func- 
tions of  the  nervous  system,  and  in  part  to  these  degenerations  of 
muscular  tissue. 

The  central  nervous  system  presents,  in  most  instances,  no  gross  ana- 
tomical changes  sufficient  to  account  for  the  symptoms  during  life.  More 
or  less  extensive  adhesion  of  the  dura  mater  to  the  inner  surface  of  the 
cranium  is  occasionally  found,  even  in  the  early  periods  of  the  disease. 
There  is  occasionally  increased  injection  of  the  pia  mater,  and  of  the  ves- 
sels of  the  brain-tissue  itself.  Later  in  the  course  of  the  affection  the  pia 
mater  is  often  cedematous,  and  sometimes  opaque,  while  in  most  cases 
there  is  moderate  distention  of  the  ventricles,  with  oedema  of  the  brain- 
substance  itself.  Some  observers  have  thought  that  the  amount  of  cere- 
bral oedema  found  after  death  was  in  direct  relation  to  the  prominence  of 
the  mental  disturbance  during  life.  When  death  takes  place  late  in  the 
course  of  the  disease,  the  convolutions  are  often  flattened,  and  spots  oi' 
softening,  due  to  imbibition  of  serum,  appear. 

According  to  Hoffmann,  frequent  changes  are  found  in  the  salivary 
f/lands.  Early  in  the  disease  they  are  firmer  in  consistence  than  normal; 
the  acini  are  found,  upon  microscopical  examination,  to  be  filled  with  large, 
multinuclear,  granular  cells  ;  later,  the  cells  lose  their  sharp  outline,  be-* 
come  turbid,  and  are  filled  with  granules.     The  glands  gradually  resume 


'  Ueber  die  Veranderungen  der  willkurlichen  Muskeln  im  Typhus  abdominaliR 
Leipzig,  1864. 
14 


210  THE  CONTINUED  FEVERS. 

their  normal  appearance.  These  changes  are  regarded  by  Liebermeister 
as  analagous  to  the  parenchymatous  degeneration  which  occurs  in  other 
organs  of  the  body.  The  parotid,  submaxillary  and  sublingual  glands  are 
implicated.      The  pancreas  is  the  seat  of  similar  changes. 

The  organs  of  respiration  show  no  anatomical  changes  peculiar  to 
enteric  fever.  The  epiglottis  is  congested — sometimes  ulcerated  or  cede- 
matous;  or,  if  diphtheria  complicates  the  case,  often  the  seat  of  false  mem- 
brane. These  changes  are  not  met  with  except  in  the  advanced  stages  of 
the  disease.  The  larynx,  as  has  already  been  pointed  out,  may  be  also 
the  seat  of  more  or  less  extensive  ulceration.  The  trachea  is  usually 
normal  in  appearance,  or  somewhat  congested.  It  is  rarely  ulcerated. 
In  the  bronchial  tubes,  those  changes  are  met  with  which  underlie  the 
various  forms  of  bronchial  catarrh  occurring  in  other  diseases. 

The  lungs  almost  constantly  j^resent  changes  referable  to  the  enfeeble- 
ment  of  the  circulation.  Hypostasis  is  very  frequent  ;  it  is  limited  to  the 
most  dependent  portions  of  the  lungs,  ^yhen  hypostasis  is  incomplete,  the 
cut  surface  of  the  congested  lung-tissue  discharges  upon  pressure  reddish 
serum  with  bubbles  of  air  ;  when  complete,  the  pulmonary  tissue  is  de- 
prived of  air,  and  we  have  the  condition  to  which  the  term  sjylenization 
has  been  applied. 

Pulmonary  oedema  is  common. 

The  evidences  of  lobular  and  lobar  pneumonia,  and  of  acute  miliary 
tuberculosis,  occur  in  a  certain  proportion  of  cases.  These  complications 
have  already  been  considered  in  a  foregoing  division  of  this  article. 
Recent  pleural  adhesions,  and  serous  and  purulent  pleural  effusions,  are 
sometimes  met  with.     The  bronchial  glands  are  occasionally  enlarged. 

Diagnosis. 

The  diagnosis  of  well-developed,  typical  cases  of  enteric  fever,  after 
the  first  week,  is  unattended  with  difficulty.  During  the  first  week,  how- 
ever, it  is  often  impossible  to  form  a  positive  diagnosis;  but  even  then 
the  nature  of  the  disease  may  be  suspected,  if  there  be  febrile  movement 
"with  nocturnal  exacerbations,  each  night  attaining  a  higher  temperature, 
and  especially  if  there  be  bleeding  at  the  nose,  diarrhoea,  either  sponta- 
neous or  readily  produced  by  laxatives,  and  appreciable  enlargement  of 
the  spleen. 

The  direct  diagnosis  of  the  developed  disease  rests  upon  the  continu- 
ance of  the  febrile  movement  and  the  appearance  of  abdominal  symp- 
toms, namely,  diarrhoea,  abdominal  pain,  enlarged  spleen,  and  tympany. 
If,  in  addition  to  these  symptoms,  lenticular  rose-spots  appear,  the  diag- 
nosis becomes  certain. 

If  neither  the  eruption  nor  the  abdominal  symptoms  occur  in  the 
course  of  the  second  week  of  the  disease,  the  diagnosis  can    be    estab- 


ENTERIC  OR  TYPHOID  FEVER.  211 

lished  only  by  a  careful  differentiation  from  the  other  febrile  disorders, 
which  more  or  less  closely  resemble  enteric  fever.  These  diseases  are 
to  be  divided  into  two  classes  :  first,  those  which  resemble  enteric 
fever  in  the  first  week  of  its  course;  and  secondly,  those  with  which  it 
is  liable  to  be  confounded  in  its  more  advanced  stages. 

To  the  first  group  belong  simple  continued  fever  and  the  exunthema- 
tous  diseases.  Diarrhoea  is  not,  however,  present  in  those  diseases,  nor 
is  their  onset  commonly  characterized  by  the  occurrence  of  marked  pro- 
dromes. Furthermore,  the  character  of  the  temperature-range  in  all  these 
affections  differs  greatly  from  that  in  typhoid  fever,  being  marked  by  an 
abrupt  rise,  which  lacks  the  distinct  morning  remissions  of  typhoid,  and 
attains  its  maximum  with  greater  rapidity.  Moreover,  in  most  cases  of 
simple  continued  fever,  the  attack  comes  to  an  end  in  less  time  than  is 
required  for  the  full  development  of  typhoid.  The  exanthemata  cannot 
be  distinguished  from  typhoid  fever  with  absolute  certainty  in  their  pre- 
emptive periods.  Nevertheless,  the  presence  of  naso-pulmouary  catarrh 
in  a  doubtful  case  would  lead  us  to  suspect  measles;  or  the  presence  of  a 
sore  throat  would  lead  us  to  suspect  scarlet  fever,  while  the  intensity  of 
the  febrile  movement  and  the  character  of  the  lumbar  pains  in  small-pox 
serve  to  distinguish  it  in  its  early  stages  from  typhoid  fever. 

After  the  first  week,  typhoid  fever  may  in  some  instances  be  confounded 
with  the  following  diseases:  typhus,  relapsing  fever,  remittent  fever,  small- 
pox, influenza,  enteritis^  peritonitis,  meningitis,  tuberculosis,  trichiniasis. 

Typhus,  see  pages  169  and  339. 

Relapsing  fever,  see  page  339. 

Remittent  fever. — Enteric  and  remittent  fevers  not  unfrequently  pre- 
vail together  in  malarious  countries,  and  all  physicians  pi-actising  in  such 
countries  are  familiar  with  that  form  of  enteric  fever  which  has  already 
been  alluded  to  under  the  name  of  typho-malarial  fever,  and  which  is,  in 
point  of  fact,  enteric  fever  modified  by  malarious  influences.  On  the 
other  hand,  severe  remittent  fever  not  infrequently  presents  strong  clini- 
cal resemblances  to  enteric,  particularl}"  when  complicated  with  marked 
intestinal  symptoms.  Thus,  in  both  diseases,  vomiting,  diarrhoea,  enlarge- 
ment of  the  spleen,  prominent  cerebral  symptoms,  and  the  condition 
known  as  the  typhoid  state,  may  occur.  The  more  important  points  of 
distinction  are  the  occurrence  of  the  eruption,  the  subcontinuous  or  im- 
perfectly remittent  character  of  the  temperature-range  in  the  second 
week,  and  the  long  course  of  enteric  fever. 

Small'pox. — Murchison  states  that  he  has  frequently  known  a  copi- 
ous eruption  of  lenticular  spots  to  be  mistaken  for  variola.  This  is  an 
error  of  diagnosis  that  should  under  no  circumstance  occur.  The  erup- 
tions are  essentially  unlike.  They  differ  in  date  of  appearance,  in  char- 
acter, and  in  evolution.  The  rose-rash  of  typhoid  does  not  appear  be- 
fore the  seventh  day  of  the  illness;  it  is  absent  from  the  face,  it  disappears 


212  THE   CONTINUED    FEVER8. 

upon  pressure,  and  undergoes  but  little  or  no  change  from  the  time  of  its 
appearance  till  it  fades,  leaving  no  trace;  that  of  variola  appears  during 
or  after  the  third  febrile  exacerbation  of  the  initial  stage,  that  is,  upon 
the  third  day  of  the  disease;  it  first  shows  itself  upon  the  face  and  hairy 
scalp.  From  the  beginning  it  is  hard,  shot-like,  and  acuminate;  it  un- 
dergoes characteristic  and  unmistakable  changes  with  great  rapidity, 
and  leaves  a  more  or  less  persistent  conspicuous  scar. 

Injluenza  occasionally  closely  resembles  enteric  fever.  The  following 
symptoms  occur  in  both  these  affections:  fever  marked  with  weakness, 
sleeplessness,  delirium,  sweating,  and  occasionally  diarrhoea;  more  or  less 
pulmonary  catarrh,  deafness,  epistaxis,  and  a  dry,  red  tongue,  are  likewise 
seen  in  both.  The  differential  diagnosis  rests  chiefly  upon  the  occurrence 
of  influenza  in  wide-spread  epidemics,  the  short  duration  of  the  attack, 
the  atypical  temperature-curve,  and  the  absence  of  the  other  abdominal 
symptoms  that  are  usually  associated  with  the  diarrhoea  of  enteric  fever, 

Enteritis  may  be  confounded  with  enteric  fever.  The  former  is,  how- 
ever, a  local  disease,  and  unattended  by  the  constitutional  disturbance* 
which  are  characteristic  of  and  essential  to  the  latter.  If  fever  be  pres- 
ent, it  is  symptomatic;  there  is  no  great  prostration,  no  delirium,  th& 
spleen  is  not  commonly  enlarged.  Rose-spots  are  absent,  the  disease  is 
of  a  relatively  short  duration,  and  the  abdominal  pain  is  more  conspicuous- 
and  severe  than  that  of  enteric  fever. 

Peritonitis  due  to  other  causes  than  perforation  is  to  be  discriminated 
from  that  arising  in  the  course  of  typhoid  fever,  by  the  antecedent  history 
of  the  case.  If  the  patient,  however,  does  not  come  under  observation 
until  after  the  appearance  of  the  symptoms,  it  may  be  impossible,  in  the- 
absence  of  a  previous  history,  to  determine  whether  they  be  due  to  per- 
foration or  not. 

Meningitis,  see  page  95. 

Acute  tuberculosis  presents  many  points  of  resemblance  to  enteric 
fever.  It  is  to  be  remarked  that  in  a  considerable  number  of  the  cases  the 
formal  rules  for  the  discrimination  of  the  two  diseases,  are,  at  the  bed- 
side, unavailing.  Only  by  a  prolonged  study  of  the  complexus  of  symp- 
toms presented  by  the  patient  does  the  diagnosis  become  possible,  and 
in  some  cases  the  most  experienced  clinician  must  be  content  to  leave  the 
decision  of  the  question  to  the  investigations  of  the  post-mortem-room. 
Hectic,  delirium,  vomiting,  varied  cerebral  symptoms,  even  palsies  and  the 
tache  cerebrate  occur  in  both  diseases;  the  absence  of  the  characteristic 
rash  of  enteric  fever  loses  its  diagnostic  value  from  the  fact  that  it  is 
often  absent  in  the  early  periods  of  life  when  the  diffculty  in  diagnosis 
usually  arises.  The  chief  points  of  difference  are  these:  in  enteric  fever 
the  temperature-range  is  typical,  or  more  or  less  closely  conformed  to  a 
definite  type,  whereas  that  of  tuberculosis  is  extremely  irregular.  In  en- 
teric fever,  diarrhoea  and  tympany  occur;  in  tuberculosis,  diarrhoea  is  rare^ 


ENTERIC    Oli   TYPHOID    FEVER.  213 

and  the  abdomen  is  apt  to  be  flat  or  even  scaphoid.  In  enteric  fever, 
epistaxis,  intestinal  hemorrhage,  and  enlargement  of  the  spleen,  occur ;  in 
meningitis  these  symptoms  are  absent.  The  headache  of  enteric  fever  is 
dull,  while  that  of  meningitis  is  acute  and  commonly  associated  with  in- 
tolerance of  light  and  sound. 

In  trichiniasis,  there  is  pyrexia  with  vomiting  and  diarrhcBa,  suc- 
ceeded after  a  short  time,  by  typhoid  symptoms.  The  resemblance  of  this 
disease  to  enteric  fever  ceases  with  those  symptoms.  The  rose-spots  do 
not  occur,  and  epistaxis  and  enlargement  of  the  spleen  are  rare;  while, 
on  the  other  hand,  the  severe  muscular,  pains  and  local  and  general  oide- 
mas  that  are  almost  constant  symptoms  in  trichiniasis,  are  not  encountered 
in  enteric  fever. 

Prognosis  and  Moetality. 

A  knowledge  of  the  duration  of  the  disease  is  of  the  utmost  import- 
ance with  reference  to  prognosis.  The  mean  duration  of  enteric  fever  is 
from  three  to  four  weeks.  The  doctrine  of  critical  days,  which  is  borne 
out  by  the  course  of  other  continued  fevers,  is  very  imperfectly  illus- 
trated in  enteric  fever.  This  is  to  be  attributed  to  the  fact  that  the 
febrile  movement  consists  of  two  distinct  parts:  a  primary  fever,  due  to 
the  specific  infection,  and  a  secondary  fever,  due  to  the  resorption  of 
septic  materials  from  the  intestinal  lesions — the  latter  beginning  before 
the  former  has  terminated — being,  so  to  speak,  engrafted  upon  it  in  such 
a  manner  that  the  two  overlap.  In  the  abortive  cases,  where  it  is  more 
than  probable  that  the  pathological  processes  of  the  ileum  do  not  go  on  to 
sloughing,  the  disease  comes  to  a  close  with  the  cessation  of  the  primary 
fever,  the  secondary  fever  being  altogether  absent.  These  cases  com- 
monly terminate  abruptly,  with  copious  sweating,  or  other  evidences  of 
true  crisis,  and  ordinarily  have  a  duration  not  exceeding  fourteen  days. 
In  cases  which  run  a  more  usual  course,  the  secondary  fever  is  superadded 
to  the  primary  at  the  close  of  the  second  or  early  in  the  third  week,  and 
always  terminates  by  prolonged  lysis.  A  precritical  and  critical  perturba- 
tion of  the  temperature  often  occurs  at  this  period,  and  it  is  then  that  the 
continuous  or  subcontinuous  fever  becomes  distinctly  remittent  in  type. 
If  a  crisis  occur  at  all,  it  takes  place  during  the  course  of  the  attack,  and 
is  marked  by  the  secondary  septic  fever  that  has  already  become  estab- 
lished before  the  termination  of  the  primary  fever  of  infection.  It  is 
common  for  the  defervescence  to  be  completed  by  the  twenty-first  or  the 
twenty -eighth  day. 

Of  200  cases  which  terminated  in  recovery,  and  in  which  the  data  of 
commencement  could  be  fixed  with  tolerable  certainty,  Murchison  found 
the  duration  to  be  from  ten  to  fourteen  days  in  7;  from  fifteen  to  twenty- 
one  days  in  49;  from  twenty-two  to  twenty-eight  days  in  111;  and  from 


214  THE    CONTINUED    FEVERS. 

twenty-nine  to  thirty-five  days  in  33.  Thus,  in  all  but  7  cases,  the  dura- 
tion of  the  sickness  exceeded  two  weeks;  in  nearly  three-fourths  it  ex- 
ceeded three  weeks;  and  in  one-sixth,  it  was  more  than  four  weeks.  The 
average  duration  of  these  200  cases  was  24.3  days.  The  average  dura- 
tion of  112  fatal  cases  observed  by  the  same  author  was  27.67  days,  and 
of  215  fatal  cases  studied  by  Hoffmann,  28.9  days. 

If  the  fever  continue  beyond  the  close  of  the  fourth  week,  it  is  almost 
certain  that  some  complication  exists  or  that  a  relapse  has  taken  place. 
Dr.  Irvine  has  shown  that  relapse  may  occur  without  an  interval  of  more 
than  twenty-four  hours  between  it  and  the  termination  of  the  primary  at- 
tack, certainly  after  an  interval  so  short  as  to  be  readily  overlooked.  The 
cases  in  which  fresh  spots  have  appeared  daily  until  the  thirty-fifth  day, 
and  the  cases  alluded  to  by  Murchison,  where,  with  mild  s3'mptoms, 
fresh  spots  appeared  almost  daily  from  the  fourteenth  to  the  sixtieth  day, 
are  to  be  accounted  for  only,  it  seems  to  me,  by  the  supposition  that  one 
or  more  relapses,  following  very  brief  and  therefore  unnoticed  intervals  of 
apyrexia,  have  thus  unduly  prolonged  the  attack.  Jenner  has  expressed 
the  opinion  that,  except  in  cases  of  relapse,  fresh  spots  never  appear 
later  than  the  thirtieth  day,  and  that  febrile  symptoms  later  than  that 
date  are  always  the  result  of  some  incidental  complication.  The  second- 
ary fever  is  often  prolonged  by  the  non-healing  of  some  of  the  intestinal 
ulcers.  Whether  the  prolongation  of  the  fever  be  due  to  this  or  to 
some  other  complication,  such  cases  show  extreme  prostration,  wasting, 
and  a  tendency  to  the  ready  breaking-down  of  tissue,  manifested  in  the 
formation  of  bed-sores,  and  other  similar  accidents  of  a  lowered  nutri- 
tion. 

Enteric  fever  may  terminate  in  recovery,  in  the  abortive  cases,  as 
early  as  the  tenth  day  ;  many  observers  have  noted  the  termination  of 
cases  of  this  variety  even  as  early  as  the  seventh  day,  and  in  very  rare 
instances,  recovery  has  taken  place  as  early  as  the  fifth  day.  Recovery 
at  so  early  a  period  suggests  the  probability  that  such  cases  are,  in  fact, 
not  instances  of  enteric,  but  of  simple  continued  fever  ;  and,  in  the  ab- 
sence of  the  characteristic  eruption  and  of  the  strongest  probability 
that  concomitant  circumstances  can  suggest,  it  would  be  better  to  suffer 
their  nosological  position  to  remain  undetermined. 

In  well-developed  cases  death  is  not  common  earlier  than  the  fourteenth 
day.  Murchison  has  noted  it  as  occurring  as  early  as  the  twelfth,  or  even 
the  sixth  day.  Several  observers  have  recorded  cases  fatal  as  early  as 
the  fifth  day,  and  a  few  instances  are  to  be  found  in  medical  literature, 
where  death  took  place  upon  the  fourth,  the  second,  or  even  the  first  day 
of  enteric  fever.  It  thus  appears  that  death  may  occur  at  any  period  of 
the  disease.  In  uncomplicated  cases,  it  is  most  common  about  the  close 
of  the  third,  or  the  beginning  of  the  fourth  week  ;  and  in  such  cases  it 
rarely  takes  place  earlier  than  the   third   week.     Death  may,   however. 


ENTERIC    OR   TYPHOID    FEVER.  215 

occur  later  than  the  fourth  week  in  cases  not  especially  complicated,  and 
in  consequence  of  the  direct  or  indirect  results  of  the  ordinary  lesions. 

Liebermeister  regards  intestinal  hemorrhage,  perforation  of  the  intes- 
tine, and  the  like,  although  representing  in  a  certain  measure  the  results 
of  changes  peculiar  to  enteric  fever,  as  complications,  and  he  formulates 
the  immediate  cause  of  death  in  cases  that  are  uncomplicated,  as  the /ever 
(md  its  consequences.  That  is  to  say,  the  patients  die  either  of  paralysis 
of  the  heart  or  paralysis  of  the  brain,  both  of  which  are  the  results  of  the 
temperature-rise. 

The  character  of  the  fever,  in  any  'particular  case,  is  of  importance  in 
determining  the  prognosis. 

Four  hundred  cases  observed  in  the  hospital  at  Basle  and  studied  with 
reference  to  the  influence  of  the  absolute  temperature  upon  the  prognosis, 
without  special  antipyretic  treatment,  gave  the  following  percentages: 

Of  those  in  whom  the  axillary  temperature  did  not  attain  40°  C.  (104° 
F.),  9.6  per  cent.  died.  Of  those  in  whom  the  axillary  temperature 
reached  or  exceeded  40°  C.  (104°  F.),  29.1  per  cent.  died.  Of  those  in 
whom  the  axillary  temperature  rose  to  or  beyond  41°  C.  (105.8°  F.),  over 
50.0  percent,  died.  Fiedler'  found  that  more  than  half  of  those  patients 
whose  temperature  had  risen  to,  or  exceeded  41.1°  C  (106°  F.),  died. 
According  to  Wunderlich,  there  is  very  great  danger  as  soon  as  the 
temperature  reaches  a  height  of  41.2°  C.  (106.16°  F.),  and  a  very  tedious 
recovery  is  the  best  that  can  be  hoped  for.  A  temperature  of  41.4°  C. 
(106.52°  F.)  is  followed  by  nearly  twice  as  many  deaths  as  recoveries, 
while  41.75°  C.  (107.15°  F.),  or  higher,  is  rarely  followed  by  other  than  the 
fatal  termination.  The  same  observer  adds  that  one  of  his  cases  of  enteric 
fever  recovered,  after  a  temperature  of  42^°  C  (107.825°  F.)  had  been 
reached  during  a  rigor  in  the  course  of  the  disease.  It  is  to  this  case, 
doubtless,  that  Murchison  refers  in  stating  that  recovery  had  been  known 
to  follow  a  temperature  of  nearly  108°  F. 

Very  high  temperatures  with  well-marked  remissions  are  of  less 
ominous  prognostic  import  than  nearly  continuous  high  temperatures  in 
which  slight  or  no  remissions  occur,  even  though  the  maxima  attained  be 
somewhat  lower.  Thus,  Wunderlich  states,  that  after  a  temperature  ex- 
ceeding 41°  C.  (105.8°  F.)  in  the  morning  hours,  death  is  almost  certain. 
Fiedler  saw  all  the  patients  whose  temperature  in  the  morning  rose  to  or 
surpassed  41.25°  C.  (106.25°  F.),  with  a  single  exception,  die;  and  of  those 
whose  morning  temperature  rose  to  40.8°  C.  (105.44°  F.),  only  upon  a 
single  day,  more  than  half  died. 

It  is  thus  apparent  that  the  daily  fluctuations  of  temperature  are  of 
very  great  importance  as  determining  the  prognosis.     The  greater  the 

'  Deutscbes  Archiv  fiir  klin.  Medicin,  Bd.  I.,  quoted  in  Leibermeister's  article,  and 
by  Wunderlich. 


216  THE   CONTINUED    FEVERS. 

daily  fluctuations,  the  more  favorable  the  prognosis.  A  fever  in  which 
the  morning  fall  is  marked,  is  much  less  disastrous  to  the  organism  than 
one  that  is  continuously  high,  and  we  may  hope  for  a  shorter  duration 
where  early  in  the  second  week  the  fever  shows  a  strong  tendency  to  re- 
mit in  the  early  hours  of  the  day,  even  when  the  evening  exacerbation  is 
relatively  high. 

The  beginning  of  the  attack  promises  a  fair  indication  for  the  dura- 
tion of  the  fever  which  is  to  be  expected.  The  more  sudden  the  appear- 
ance of  the  disease,  and  the  more  rapid  the  rise  of  temperature  in  the  first 
week,  so  much  the  more  should  we  expect  in  general  a  short,  or  even  abor- 
tive attack  (Liebermeister). 

A  closer  study  of  the  temperature,  during  the  first  week,  than  is  cus- 
tomary with  American  physicians,  is  desirable  in  every-day  practice.  In 
uncomplicated  cases  the  temperature  of  this  period  is  the  key  to  the  tem- 
perature of  the  attack,  and  is  therefore  of  the  greatest  importance  in  re- 
gard to  prognosis.  By  reference  to  the  schematic  representation  of  the 
temperature-range,  and  to  that  of  a  mild  case  recorded  by  Wunderlich, 
(see  pp.  154  and  157),  it  will  be  seen  that  the  height  which  the  tempera- 
ture attains  by  the  end  of  the  first  week  is  nearly  or  about  that  which  is 
to  be  expected  during  the  course  of  the  attack.  Unless  complications  oc- 
cur, the  temperature  rises  but  little  above  that  point.  Moreover,  if  the 
temperature  at  the  end  of  the  first  week  be  of  moderate  elevation,  the 
fever  will  probably  not  only  be  of  moderate  intensity,  but  its  duration 
will  be  correspondingly  short. 

The  character  of  the  circulation  and  the  action  of  the  heart,  both  of 
which  are  directly  modified  by  the  fever,  are  of  great  moment  in  prog- 
nosis. Tlie  most  frequent  immediate  cause  of  death  is  cardiac  failure. 
Hence,  a  close  study  of  the  signs  and  symptoms  referable  to  the  circula- 
tion is  scarcely  less  important  than  the  close  scrutiny  of  the  temperature- 
range. 

While  the  impulse  of  the  heart  retains  to  some  extent  the  force  of 
health,  and  the  systolic  sound  remains  distinct,  the  dangers  belonging  di- 
rectly to  failure  of  the  circulation,  or  to  its  indirect  consequences,  remain 
at  a  minimum,  although  the  temperature-rise  may  be  considerable.  If 
these  remain  favorable  until  the  time  at  which  decided  remissions  in  tem- 
perature occur,  the  prognosis  is  correspondingly  hopeful.  The  pulse, 
therefore,  becomes  in  enteric  fever  a  symptom  of  the  greatest  importance. 
Those  clinicians  who  deride  the  time-honored  habit  of  pulse-study  and 
pulse-counting,  ignore  one  of  the  most  valuable  methods  of  investigation 
in  febrile  disorders.  It  is  further  true  that  the  trained  finger  is  an  in- 
strument of  greater  precision,  and  more  useful  for  all  purposes  at  the  bed- 
side, than  the  most  ingeniously  constructed  sphygmograph. 

While  the  pulse  remains  strong  and  of  moderate  frequency,  the  heart 
cannot  be  weak,  nor  are  the  most  serious  dangers  of  uncomplicated  cases 


ENTERIC  OB  TYPHOID  FEVER.  217 

to  be  immediately  feared.  When  the  pulse  becomes  feeble,  or  its  fre- 
quency for  any  length  of  time  exceeds  130  beats  per  minute,  the  progno- 
sis is  in  a  considerable  measure  rendered  unfavorable  by  this  very  fact. 
In  children,  or  exceedingly  nervous  persons,  or  where  a  special  tendency 
to  pulse-frequency  exists,  a  rapid  pulse  is  less  ominous.  The  frequency 
toward  the  end  of  the  fever  is  often  very  variable;  a  decided  fall,  therefore, 
has  less  direct  value  in  prognosis  than  in  most  other  febrile  affections. 

From  a  collection  of  histories  of  cases  in  the  hospital  at  Basle,  in  which 
the  death-rate  was  about  sixteen  or  seventeen  per  cent.,  Liebermeister 
found  that,  of  those  in  whom  the  pulse  reached  or  exceeded  120,  40  out  of 
63  died.  Of  these  63  there  were  37  in  whom  the  pulse  did  not  rise  above 
140:  of  this  number  19  died;  26  patients  had  pulse-frequency  which  rose 
above  140,  and  21  of  them  died.  It  rose  above  150  in  twelve  cases,  and 
11  of  them  died. 

The  disorders  of  the  nervous  system,  which  chiefly  result  from  the 
long-continued  high  temperature,  and  particularly  somnolence,  stupor, 
and  delirium,  vary  greatly  in  different  individuals,  in  proportion  to  their 
ability  to  endure  fever,  rather  than  invariably  with  the  height  of  the 
temperature.  In  general  it  is,  however,  true  that  those  cases  in  which 
cerebral  symptoms  are  most  prominent  and  severe,  are  the  most  danger- 
ous, and  that  the  prognosis  becomes  less  hopeful  as  the  functions  of  the 
brain  become  more  deeply  deranged.  I  turn  again  to  the  invaluable  statis- 
tics of  Liebermeister.  Of  983  cases  in  whom  the  disease  ran  its  course  in 
the  Basle  Hospital,  without  any  specially  noteworthy  brain-symptoms,  34, 
or  3.5  per  cent.,  died.  Of  191  cases  attended  by  slight  delirium  or  excite- 
ment, appearing  only  at  night  or  for  a  brief  period,  38,  or  about  19.8  per 
cent.,  died.  Of  176  attended  with  well-marked  delirium,  96,  or  54  per 
cent.,  died.  Of  43  cases  in  which  stupor  or  coma  was  present,  30,  or  70 
per  cent.,  died. 

Disturbances  of  the  general  nervous  system,  not  due  to  the  action 
of  the  fever,  but  which  are  accidental,  such  as  apoplexies,  local  or  general 
convulsions,  or  the  fixed  head-pains,  vomiting,  and  local  palsies  arising  from 
meningitis,  are  of  great  prognostic  import,  seeing  that  they  point  to  spe- 
cial lesions  of  a  serious  character,  which  are  not  of  the  fever,  but  super- 
added to  it.  Less  grave  are  the  spinal  palsies  which  arise  as  complications 
in  the  later  stages  of  the  attack  or  during  convalescence,  and  which  have 
already  been  described. 

Before  entering  upon  the  consideration  of  the  influence  of  individual 
peculiarities  upon  the  prognosis,  it  is  necessary  to  turn  our  attention  to 
the  general  mortality. 

The  rate  of  mortality  in  private  practice  is  undoubtedly  lower  than 
among  patients  treated  in  hospitals.  This  is  due  to  various  causes,  among 
which  are  to  be  named  the  better  previous  condition  of  those  patients 
who  can  afford  the  expense  of  treatment  in  private  practice;  the  fact  that. 


218  THE  CONTINUED  FEVERS. 

among'  the  poorer  classes,  principally  the  more  severe  cases  seek  admission 
into  the  hospitals,  and  the  further  fact  that  hospital  patients  suffering' 
from  typhoid  rarely  come  under  treatment  until  the  disease  has  made 
considerable  progress.  It  is  a  matter  of  common  observation  that  the 
mortality  of  cases  neglected  in  the  beginning  of  the  disease  is  very  much 
higher  than  that  of  those  who  early  come  under  treatment. 

The  statistics  of  private  practice,  however,  are  in  most  instances  unre- 
liable, being  commonly  based  upon  insufficient  collections  of  facts,  and 
too  often  not  altogether  free  from  the  suspicion  of  bias  on  the  part  of  the 
observers,  who  tabulate  them  mostly  with  a  view  of  illustrating  the  sup- 
posed efficacy  of  particular  methods  of  treatment. 

Hospital  statistics  are  more  trustworthy.  They  are  based  upon  facts 
observed  by  many  different  physicians,  and  in  collections  sufficiently  large. 
They  are,  it  is  true,  open  to  the  objection  that  for  many  reasons,  of  which 
the  chief  are  given  above,  they  indicate  a  death-rate  somewhat  too  high. 

The  following  statistics  indicate  the  hospital  death-rate  of  enteric 
fever. 

The  London  Fever  Hospital  : 

1,  A  period  of  twenty-one  years,  during  which  all  pauper  patients 
were  received;  8,000  cases,  1,519  deaths;   mortality  18.9  per  cent. 

2.  A  period  of  nine  years,  during  which  pauper  cases  have  been  ex- 
cluded, and  only  patients  of  a  better  class,  mainly  artisans,  servants,  po- 
licemen, clerks,  and  other  persons  sufficiently  well  off  to  occupy  private 
rooms,  have  been  received;  590  cases,  80  deaths;  mortality  15.9  percent. 

Cases  are  included  in  the  above  statistics  which  were  admitted  mori- 
bund and  died  within  48  hours. 

The  Pauper  Hospital  at  Homerton  :  1,509  cases,  255  deaths;  mortality 
16.8  per  cent. 

The  Stockwell  Pauper  Hospital  :  1,233  cases,  301  deaths;  mortality 
23.6  per  cent. 

St.  George's:  387  cases,  76  deaths;  mortality  19.6  per  cent. 

Guy's:  395  cases,  57  deaths;  mortality  19.3  per  cent. 

University  College:  163  cases,  29  deaths;  mortality  17.7  per  cent. 

St.  Bartholomew's:   635  cases,  104  deaths;  mortality  16.3  per  cent. 

St.  Thomas's:  445  cases,  70  deaths;  mortality,  15.7  per  cent. 

Middlesex:  461  cases,  72  deaths;  mortality  15.6  per  cent. 

King's  College:  318  cases,  39  deaths;  mortality  12.3  per  cent. 

Total  number  of  cases,  14,125;  deaths,  2,522;  rate  of  mortality  17.8 
per  cent. 

Dr.  Murchison  found  that  of  27,051  cases  collected  from  various 
sources,  and  many  of  which  have  been  included  in  the  foregoing  list, 
4,723  proved  fatal,  a  death-rate  of  17.45  per  cent. 

Jaccoud,  with  a  collection  of  60,000  cases,  observed  a  mortality  of 
about  20  per  cent. 


ENTERIC  OR  TYPHOID  FEVER.  219 

The  General  Hospital  of  Vienna,  with  17,000  cases,  has  a  mortality  of 
22.5  per  cent. 

The  Hospital  at  Basle,  with  1,718  cases,  shows  a  mortality  of  27.3  per 
cent.  And  the  principal  Continental  hospitals  give,  according  to  Dr. 
Cayley,  a  mortality  varying  from  16  to  25  per  cent. 

English  army  statistics,  for  six  years  ending  1877,  are  as  follows  :  On 
Home  Service,  545  cases,  131  deaths  ;  mortality  24  per  cent.  On  For- 
eign Service,  1,383  cases,  564  deaths;  mortality  40.7  per  cent. 

Royal  Navy:  Period  of  six  years  ending  1878;  414  cases,  110  deaths; 
mortality  26.5  per  cent. 

Massachusetts  General  Hospital:  303  cases,  42  deaths;  mortality  13.5 
per  cent. 

Of  73  cases  analyzed  by  Flint,  18  were  fatal,  or  about  24  per  cent. 

The  foregoing  figures  show  in  general  the  results  of  the  expectant 
treatment  of  enteric  fever,  although  they,  without  doubt,  include  a  small 
proportion  of  cases  treated  upon  special  plans. 

Age  exerts  an  undoubted  influence  on  the  mortality  of  enteric  fever. 
Murchison  states  that  of  1,772  cases,  in  which  the  age  was  known,  the 
average  was  21.25  years;  of  the  cases  which  recovered,  1,444,  the  average 
was  20.7  years  ;  of  those  which  died,  328,  the  average  age  was  23.54 
years. 

I  have  rearranged  one  of  Dr.  Murchison's  tables  in  such  a  manner  as 
to  show  the  number  of  cases  admitted  to  the  London  Fever  Hospital  in 
each  of  the  decennial  periods  of  life  during  twenty-three  years,  together 
with  the  corresponding  number  of  deaths  and  the  percentage  of  mor- 
tality. 

There  were,  under  10  years,     616  cases,     70  deaths,  or  11.36  per  cent. 


Between 

10  and 

20 

2 

762 

20 

30 

1 

,764 

30 

40 

498 

40 

50 

188 

50 

60 

56 

GO 

70 

25 

70 

80 

2 

Age  doubtfu 

1, 

77 

397 

14.37 

361    ' 

20.46 

129 

25.90 

47 

25.00 

17 

'    30.35 

11 

44.00 

1 

'    50.00 

1 

1.29 

This  table  shows  that,  although  the  death-rate  of  enteric  fever  is  dis- 
tinctly influenced  by  the  age  of  the  patient,  the  extent  of  this  influence 
is  much  less  than  in  typhus.  Its  figures  are,  however,  misleading,  unless 
allowance  be  made  for  the  fact  that,  for  reasons  that  are  obvious,  a  rela- 
tively smaller  number  of  individuals  sick  of  enteric  fever  find  their  way 
into  hospitals  in  the  early  periods  of  life  than  among  adults.  In  point  of 
fact,  Avith  children  the  prognosis  is  decidedly  more  favorable  than  it  is 
later  in  life.     This  is  to  be  explained,  in  part,  by  the  comparative  infre- 


220  THE  CONTINUED  FEVERS. 

<5uency  of  severe  cases  of  enteric  fever  in  childhood,  the  intestinal  lesions 
being,  as  a  rule,  neither  so  extensive  nor  so  marked,  and  complications 
and  sequels  neither  so  frequent  nor  so  severe;  partly  by  the  fact  that  the 
temperature,  though  often  attaining  great  heights,  is  less  continuous  on 
the  one  hand,  and  on  the  other  much  better  borne,  so  that  an  intense 
febrile  movement  is  less  apt  to  give  rise  to  the  degenerative  changes  in 
the  heart  which  are  so  frequently  the  immediate  cause  of  death.  After 
forty  years  of  age  the  mortality  rapidly  increases.  Among  1,743  cases 
treated  in  the  hospital  at  Basle,  there  were  130  who  were  more  than  forty 
years  old  ;  of  these,  39,  or  30  per  cent.,  died  ;  while  the  mortality  among 
the  cases  under  forty  amounted  to  only  11.8  per  cent. 

Sex  influences  the  mortality  of  enteric  fever  to  an  insignificant  extent. 
Most  observers  state  that  the  death-rate  among  females  is  slightly  greater 
than  that  among  males.  Murchison  has  shown  that  this  excess  of  the 
mortality  among  females  is  not  accounted  for  by  the  influence  of  child- 
bearing  upon  the  course  of  the  disease,  for  it  is  much  greater  between  the 
ages  of  five  and  fifteen  than  between  the  ages  of  fifteen  and  forty-five. 
After  the  age  of  forty  the  mortality  is  greater  among  men  than  among 
"women. 

The  season  of  the  year  does  not  appreciably  influence  the  death-rate 
in  enteric  fever. 

TTie  personal  habit  and  the  constitution  of  patients  are  of  importance. 
Thus,  it  is  a  well-known  fact  that  corpulent  persons  do  not  bear  the  dis- 
ease so  well  as  those  who  are  lean;  they  are  liable  to  a  more  intense 
febrile  movement  and  are  less  able  to  resist  its  destructive  influence  upon 
the  tissues.  Even  debilitated,  ill-nourished  or  anaemic  individuals  bear 
the  disease  better  than  the  corpulent. 

Nervous,  excitable  persons  manifest  the  symptoms  of  the  disease,  and 
particularly  those  referable  to  the  nervous  system,  much  more  decidedly 
than  those  of  a  phlegmatic  or  torpid  disposition. 

Those  whose  habits  have  been  intemperate  or  who  suffer  from  diseases 
of  the  kidney,  or  are  gouty,  are  especially  liable  to  the  gravest  accidents 
■of  enteric  fever. 

Pregnancy  is  regarded  by  most  observers  as  a  most  formidable 
■complication  of  enteric  fever;  the  mother  usually  aborts  or  miscarries, 
and  considerable  hemorrhage  is  apt  to  occur.  Murchison,  however, 
looks  upon  it  as  a  less  serious  complication  than  is  commonly  imagined. 
The  prognosis  is  undoubtedly  unfavorably  influenced  by  the  puerperal 
state. 

The  occurrence  of  the  fatal  accidents  to  which  the  patient  is  liable,  by 
reason  of  the  existence  of  the  intestinal  lesions,  cannot  be  foreseen  ;  but 
the  percentage  of  deaths  from  these  causes  is  small,  and  becomes  still 
smaller  if  all  but  those  cases  properly  treated  from  the  early  days  of  the 
attack,  are  thrown  out.     In  this  sense,  it  may  be  said  that  the  prognosis 


ENTERIC  OR  TYPHOID  FBVER.  221 

is  influenced  by  the  treatment,  and  the  time  at  which  the  treatment  is 
commenced. 

Death  may  take  place  by  coma  at  the  end  of  the  second,  or  early  in 
the  third  week,  about  the  time  of  the  termination  of  the  primary  fever. 
It  much  more  frequently  takes  place  by  asthenia  in  the  end  of  the  third 
or  during  the  fourth  week,  or  at  a  later  period.  Finally,  it  may  occur  by 
sudden  collapse  in  consequence  of  intestinal  hemorrhage,  perforation,  or 
sudden  failure  of  the  heart,  at  any  period  later  than  the  end  of  the  second 
week. 

Tkeatment. 

Under  this  division  of  the  subject  are  embraced  the  following  topics, 
each  of  which  demands  separate  consideration:  1.  Prophylaxis.  2.  The 
general  management  of  the  patient  and  dietetics.  3.  Special  forms  of 
treatment.  4.  The  expectant  or  "  rational "  treatment.  5.  The  treatment 
of  special  symptoms,  complications,  and  sequels.  6.  The  management  of 
the  patient  during  convalescence. 

I.   PROPHYLAXIS. 

A  growing  knowledge  of  the  various  ways  in  which  enteric  fever  is 
propagated,  and  of  the  habits  of  its  exciting  cause,  warrants  the  confident 
belief  that  the  disease  may  not  only  be  greatly  restricted  in  its  prevalence,, 
but  even  that  it  may  be  ultimately  gotten  rid  of  altogether.  An  efficient 
prophylaxis  is  theoretically  within  reach ;  its  practical  realization  in  com- 
munities in  which  the  disease  is  endemic,  depends  upon  the  energy  and 
steadfastness  with  which  measures  for  the  destruction  of  the  poison  and 
the  prevention  of  its  spread  are  carried  out.  What  these  measures  are 
is  to  be  directly  deduced  from  the  statements  made  regarding  the  causa- 
tion of  enteric  fever  in  a  previous  section  of  this  article.  They  belong  tO' 
the  subject  of  public  hygiene,  and  are  of  sufficient  importance  to  demand 
the  closest  attention  of  all  local  and  general  sanitary  organizations,  for 
enteric  fever  destroys  more  lives,  that  could  be  saved,  than  any  other 
acute  disease  whatever.  They  are,  nevertheless,  largely  within  the  per- 
sonal control  of  the  physicians  of  every  community.  It  is  the  highest 
duty  of  the  doctor  to  see  to  it  that  no  new  case  of  disease  arise  by  direct 
or  indirect  contagion  from  any  patient  under  his  care.  In  enteric  fever 
we  have  to  do  with  a  disease  in  which  this  is  wholly  possible.  Not  only 
may  the  spread  of  the  contagion  be  prevented,  but  the  poison  may  be 
wholly  and  absolutely  destroyed;  and  that  before  it  has  acquired  the 
power  of  infection.  The  remark  is  certainly  true,  that  "  measures  of  pro- 
phylaxis will  be  efficient  in  proportion  to  the  strength  of  our  belief  in  the 
material  nature  of  the  typhoid  poison,  and  in  the  possibility  of  destroy- 


222  THE  CONTINUED  FEVERS. 

ing  it  or  preventing  its  spread."  It  is  to  be  regretted  that  this  belief  has 
but  little  strength  in  the  minds  of  many  physicians — deeply  regretted  that 
the  study  of  disease  from  an  etiological  standpoint  occupies  so  little  as  it 
does  the  attention  of  most  practitioners  in  their  every-day  work.  The 
danger  that  a  house-epidemic  of  enteric  fever  may  arise  from  a  single 
case  suffered  to  become  a  focus  of  contagion,  is  to  be  constantly  borne 
in  mind.  It  is  not  house-epidemics  alone  that  are  to  be  prevented,  but 
also  the  spread  of  the  disease  to  distant  points  by  means  of  the  pollution 
of  running  streams,  of  the  air,  or,  in  cities,  b}'^  continuous  sewers  that  may 
convey  the  poison  to  comparatively  remote  localities. 

The  one  efficient  measure  that  includes  all  others  is  the  proper  treat- 
ment of  the  dejections. 

The  dejections  of  every  case  should  be  promptly  and  thoroughly  disin- 
fected. The  destruction  of  organisms  in  the  stools,  and  the  arrest  of 
their  development,  may  be  accomplished  by  the  action  of  powerful  chem- 
ical agents. 

For  this  purpose  solutions  of  carbolic  acid,  in  the  proportion  of  one  to 
twenty  or  one  to  forty,  or  of  sulphate  of  iron,  or  of  chloride  of  zinc,  are 
to  be  employed.  Liebermeister  uses  a  porcelain  bed-pan,  the  bottom  of 
which  is  strown  with  sulphate  of  iron  each  time  before  being  used.  Im- 
mediately after  the  passage,  crude  muriatic  acid  is  poured  over  the  fecal 
mass  in  considerable  quantities,  as  much  as  one-third  or  one-half  of  the 
amount  of  the  discharges  being  used.  He  also  advises  that,  when  prac- 
ticable, the  contents  of  the  bed-pan  should  be  emptied  into  trenches  dug 
anew  at  short  periods,  and  carefully  filled  up,  care  being  taken  that  they 
are  located  at  a  distance  from  the  sources  of  water-supply.  Except  in 
rural  districts,  this  is  of  course  impossible,  and  the  dejections  must  be 
emptied  into  the  ordinary  water-closets  or  privy-vaults. 

All  bedding  and  articles  of  clothing  soiled  with  the  excreta  of  the  pa- 
tient must  be  immediately  removed  and  thrown  into  water  containing 
carbolic  acid  or  chloride  of  zinc,  and  thoroughly  boiled  within  the  course 
of  a  few  hours. 

Search  must  in  all  instances  be  made  for  the  original  cause  of  infec- 
tion, and  measures  taken  to  correct  faulty  arrangements  which  lead  to 
the  pollution  of  drinking-water  or  of  the  air. 

n.    THE  GENERAL  MANAGEMENT   OF  THE  PATIENT   AND  DIETETICS. 

The  successful  treatment  of  enteric  fever  is  largely  dependent  on  the 
attention  which  is  given  to  the  general  management  and  nursing  of  the 
patient. 

In  the  first  place,  it  is  important  to  see  that  he  is  not  exposed  to  the 
continual  action  of  the  poison.  If  the  original  source  of  infection  be 
found,  upon  inspection,  to  be  connected  with  faulty  sanitary  arrange- 


ENTERIC  OR  TYPHOID  FEVER.  223 

tnents  in  the  house  or  neighborhood,  it  may  be  necessary  to  remove  the 
patient  to  more  favorable  surroundings. 

In  hospitals,  enteric  fever  patients  are  generally  treated  side  by  side 
with  patients  suffering  with  other  diseases.  This  practice  is  unattended 
with  the  danger  of  infection  if  proper  precautionary  measures  be  taken 
with  reference  to  the  disinfection  and  removal  of  the  dejections,  and  the 
cleanliness  of  the  patient's  person  and  bedding. 

In  private  practice,  patients  commonly  come  under  observation  during 
the  prodromPc  stage,  or  early  in  the  first  period  of  the  disease.  Not  in- 
frequently they  complain  merely  of  general  malaise  and  evening  headache. 
Sometimes  they  are  under  the  impression  that  they  have  caught  cold,  but 
much  more  commonly  they  are  found  to  be  suffering  from  diarrhoea  in- 
duced by  purgative  medicine  taken  under  the  impression  that  they  are 
suffering  from  a  "  bilious  attack."  If  the  fever  has  already  declared  itself, 
the  use  of  the  thermometer  will  put  the  physician  upon  his  guard  as  to 
the  nature  of  the  sickness,  but  even  in  those  cases  seen  during  the  period 
of  prodromes,  the  languid  expression  of  the  patient,  his  general  lassitude 
and  constitutional  disturbance,  are  usually  greater  than  commonly  attend 
tlie  ordinary  trivial  ailments  to  which  the  patient  attributes  his  symp- 
toms, and  are  sufficient  of  themselves  to  excite  a  suspicion  as  to  the 
nature  of  the  disease.  Such  a  suspicion  alone  should  be  sufficient  war- 
rant to  order  absolute  rest  in  bed.  If  the  suspected  case  prove  to  be  in 
fact  a  simple  ailment,  but  little  time  is  lost  to  the  patient;  if,  on  the 
other  hand,  his  symptoms  prove  to  have  been  those  of  the  forming  stage 
of  enteric  fever,  the  early  rest  in  bed  cannot  fail  to  favorably  influence 
the  subsequent  course  of  his  attack.  x\ll  observers  agree  in  the  state- 
ment that  the  course  of  the  disease  is  more  favorable,  and  the  mortality 
lower,  in  those  cases  which  are  treated  from  the  beginning  of  the  attack, 
than  in  those  not  coming  under  medical  care  until  after  the  disease  is 
fully  developed.  Some  of  the  worst  cases  of  enteric  fever  occur  in  those 
wlio  have  struggled  against  the  early  symptoms  of  the  disease,  and  con- 
tinued to  go  about  and  to  perform  their  daily  duties,  until  forced  to  be- 
take themselves  to  bed  by  the  intensity  of  the  febrile  movement,  the 
urgency  of  diarrhoea,  or  by  sheer  weakness.  There  is  reason  to  believe 
that  the  fatigue  of  long  journeys,  and  particularly  of  railroad  travelling, 
exerts  a  most  injurious  influence  upon  the  subsequent  course  of  the  at- 
tack, in  those  who,  after  its  commencement,  undertake  such  journeys  in 
order  to  reach  home.  Of  primary  importance,  then,  is  absolute  rest  in  bed 
from  the  beginning  of  the  attack.  The  patient  is  not  to  be  allowed  to 
rise  for  any  purpose  whatever  from  the  beginning  of  his  sickness  until 
some  days  after  complete  defervescence.  The  use  of  the  urinal  and  the 
bed-pan  must  be  rigidly  insisted  upon.  Many  patients  declare  that  it  is 
impossible  for  them  to  empty  the  bowel  in  the  recumbent  posture;  but, 
after  trial,  they  soon  acquire  the  habit. 


224  THE    CONTINUED    FEVERS. 

The  room  should  be  large  and  well  ventilated.  The  temperature 
should  be  maintained  uniformly  at  15.5°— 21°  C.  (60°— 70"*  F.).  When 
practicable,  it  is  desirable  that  the  patient's  apartment  should  be  heated 
by  an  open  fireplace  rather  than  by  hot  air,  and  that  communicating  rooms 
be  used,  between  which  the  doors  may  be  kept  open,  and  from  one  to  the 
other  of  which  the  bed  of  the  patient  may  be  from  time  to  time  trans- 
ferred, a  window  of  the  unoccupied  room  being  kept  constantly  open. 
This  arrangement  not  only  secures  abundant  and  satisfactory  ventilation, 
but  the  change  also,  to  a  considerable  extent,  favorably  influences  the 
mental  condition  of  the  patient.  Thorough  ventilation  must  in  all  cases  be 
secured  both  day  and  night,  and  whilst  direct  drafts  are  to  be  avoided,  it 
must  be  impressed  upon  the  attendants  that  fever-patients  are  not  likely 
to  take  cold. 

Mental  quietude  is  no  less  important  than  bodily  repose.  Visitors  are 
not  to  be  admitted  to  the  patient  during  the  course  of  the  fever ;  all 
business  affairs  and  matters  of  annoyance  are  to  be  withheld  from  him; 
disturbing  influences  of  every  kind  are  to  be  avoided.  Even  pictures, 
ornaments,  or  articles  of  furniture,  that  especially  attract  his  attention, 
may  become  causes  of  disturbance,  and  should  then  be  quietly  removed. 
His  attendants  should  care  for  his  wants  quietly,  noiselessly,  holding  no 
conversation  with  him  except  to  reply  briefly  to  his  questions;  even  in 
the  early  days  of  convalescence,  the  visitations  of  friends  should  be  re- 
stricted in  number  and  length  of  time.  Among  the  minor  duties  of  the 
nurse,  which  are,  however,  of  not  inferior  importance,  is  the  frequent 
changing  of  the  position  of  the  patient's  body,  moistening  his  mouth, 
cleansing  his  tongue,  the  prevention  of  the  accumulation  of  sordes,  and 
the  most  scrupulous  care  of  his  person  in  other  respects.  If  the  evacua- 
tion of  the  urine  and  faeces  in  the  bed  cannot  be  prevented,  the  discharges 
and  soiled  clothing  are  to  be  changed  without  loss  of  time.  In  such  cases 
it  is  sometimes  necessary  to  use  two  beds,  the  patient  being  rolled  or  lifted 
in  the  horizontal  position  by  the  attendants,  from  one  to  the  other. 

Fluid  is  to  be  administered  without  stint.  The  best  drink  is  pure 
water,  either  of  the  temperature  of  the  room,  or  iced.  The  kind  of  bever- 
age may,  however,  be  left  to  the  choice  of  the  patient.  It  should  be 
changed  from  time  to  time,  Apollinaris,  seltzer,  or  other  similar  mineral 
waters,  lemonade,  iced  tea  with  lemon-juice,  wine  and  water,  milk  and 
water,  or  milk  and  seltzer,  koumiss,  thin  barley-water,  or  water  com- 
mingled with  jelly,  are  all  grateful  ;  but  the  amount  of  fluid  must  be  as 
great  as,  or  even  greater,  than  that  consumed  in  health. 

It  often  happens  that  patients  fail  to  partake  of  the  necessary  amount 
of  drink,  unless  it  is  proffered  them,  even  when  apparently  fully  conscious. 
It  is  important,  therefore,  that  the  nurse  offer  the  patient  drink  at  short 
intervals.  It  is  often  taken  with  eagerness,  though  not  asked  for.  The 
amount  at  each  time  should,  however,  be  moderate. 


ENTERIC  OR  TYPHOID  FEVER.  225 

The  diet  should  be  rigidly  restricted.  The  directions  of  the  physician 
as  to  its  kind,  quantity,  and  the  intervals  at  which  it  is  to  be  given,  must 
be  definite  and  explicit.  A  record  of  the  amounts  given,  as  well  as  of 
the  intervals  between  the  administrations  of  food,  is  to  be  kept  by  the  at- 
tendant and  submitted  at  each  visit.  Neither  general  directions  nor 
general  reports,  are  sufficient.  The  diet  throughout  should  be  nutritious, 
easily  digestible,  and  for  the  most  part  liquid.  If  overfed,  the  patient 
suffers  from  indigestion  and  an  aggravation  of  the  intestinal  symptoms, 
particularly  the  diarrhoea;  if  underfed,  the  disturbances  of  nutrition  in- 
crease, and  convalescence  will  be  prolonged.  It  is  desirable  to  give  the 
maximum  quantity  of  proper  food  that  can  be  assimilated,  and  not  to  ex- 
ceed this  amount.  How  much  it  may  be  can  only  be  determined  by 
careful  study  of  individual  cases.  During  the  earlier  stages  of  the  dis- 
ease, up  to  the  end  of  the  first  week,  it  is  desirable  not  only  that  the  diet 
of  the  patient  should  be  very  digestible,  but  it  is  also  important  that  it 
should  be  of  only  moderate  amount.  During  this  time  the  hyperplasia  of 
the  intestinal  glands  is  taking  place,  and  every  possible  intestinal  irritant 
is  to  be  avoided.  Up  to  this  time  the  tissues  of  the  body  retain,  in  a 
measure,  the  nutrition  of  health,  and  an  alimentation  restricted  in  quan- 
tity is  free  from  the  dangers  that  attend  it  later  in  the  course  of  the 
attack.  After  the  beginning  of  the  second  week  as  much  food  is  to  be 
given  as  can  be  properly  digested. 

Milk  occupies  the  first  place  among  fever-foods,  but  it  is  neither  to  be 
given  indiscriminately  in  all  cases,  nor  is  it  to  be  given  in  unlimited 
quantities.  Some  persons  digest  pure  milk  imperfectly  and  only  in  small 
amounts,  while  others  are  able  to  digest  as  much  as  two  quarts  of  rich 
milk  in  the  course  of  twenty-four  hours.  The  first  step  in  the  digestion 
of  milk  is  the  formation  of  curd.  If  large,  firm  curds  form  in  the  stomach, 
milk  becomes  in  fact  a  solid  food.  The  formation  of  such  curds  may  be 
in  part  avoided  by  the  addition  of  lime-water  to  the  milk,  in  the  propor- 
tion of  one  part  of  the  former  to  three  or  five  of  the  latter,  and  by  ad- 
ministering the  milk  very  slowly  and  in  small  quantities  at  a  time.  Milk 
may  be  given  raw  or  boiled,  warm  or  frozen,  or  it  may  be  coagulated  into 
soft  curds  by  means  of  rennet.  Buttermilk  is  often  an  exceedingly 
grateful  cha^nge  to  patients  weary  of  milk  as  it  is  ordinarily  administered 
in  the  course  of  fever. 

Meat-broths  of  moderate  strength,  containing  a  little  barley  and 
flavored  with  vegetable  essences,  are  also  to  be  given.  They  may  be  made 
of  beef,  mutton,  veal,  or  chicken,  and  should  be  varied  from  day  to  day. 
Sometimes  the  addition  of  claret  or  port  serves  to  overcome  the  growing 
disgust  which  this  kind  of  food  after  a  time  excites  in  certain  patients. 
Meat-juice  may  also  be  given,  hot,  cold,  frozen,  or  in  the  form  of  jelly, 
as  the  patient  fancies  it.  Clam-soup,  or  oyster-soup,  made  by  chop- 
ping the  oysters  and  the  addition  of  milk,  may  be  occasionally  substi- 
15 


226  THE  CONTINUED  FEVERS. 

tuted  for  the  meat-broths.  Once  or  twice  a  day,  coffee  or  tea,  well 
diluted  with  milk,  may  be  administered.  If  the  appetite  requires  it,  a 
moderate  quantity  of  thickened  gruel,  or  arrow-root,  or  of  bread  and  milk, 
may  be  given  once  a  day.  Some  patients  appear  to  do  better  with  an 
occasional  meal  of  such  semi-solid  food,  but  in  general  terms  it  may  be 
said  that  starchy  articles  of  diet  are  objectionable. 

Food  should  be  administered  at  intervals  of  two  hours  during  the  day 
and  three  during  the  night,  the  milk  and  broths  alternating.  Where  the 
quantity  taken  at  a  time  is  small,  or  where  the  prostration  is  extreme, 
the  intervals  must  be  shortened.  During  convalescence,  solid  food  may 
be  gradually  resumed,  but  the  diet  must  for  a  long  time  be  of  a  kind 
readily  digested.  The  patient  should  be  warned  of  the  risk  attending 
the  eating  of  the  seedy  fruits,  olives,  nuts,  and  similar  indigestible  sub- 
stances, for  many  weeks  after  convalescence  is  fairly  established. 

Alcoholic  stimulants  form  no  necessary  part  of  the  routine  treatment 
of  enteric  fever.  During  the  primary  fever — that  is  to  say,  up  to  the  end 
of  the  second  week  of  the  disease — their  use,  except  to  meet  special  indi- 
cations, is  probably,  in  most  cases,  injurious  rather  than  beneficial.  Dur- 
ing the  secondary  fever  the  indications  which  call  for  their  administration 
are  twofold:  of  these  the  first  is  dependent  upon  the  degree  of  general 
prostration,  as  particularly  manifested  by  weakness  of  the  heart's  action, 
and  upon  the  prominence  of  nervous  symptoms.  Thus,  a  feeble  or  imper- 
ceptible cardiac  impulse,  and  a  correspondingly  faint,  or  almost  inaudible, 
systolic  sound,  call  for  their  administration ;  while  the  evidences  of  nervous 
prostration  usually  developed  at  the  same  time  are  only  to  be  successfully 
combated  by  the  abstraction  of  heat  or  the  administration  of  stimulants, 
or  these  two  combined.  The  second  indication  for  the  use  of  stimulants 
at  this  period  of  the  disease  is  related  to  the  nature  of  the  intestinal 
lesion.  It  is  now  that  the  process  of  sloughing  is  going  on;  the  fever  of 
this  period  is  due  to  gangrene  and  ulceration.  In  accordance  with  well- 
established  principles  of  surgery,  external  gangrene,  attended  with  septic 
fever  and  general  depression,  is  treated  by  the  free  administration  of  al- 
cohol. The  fact  that  in  typhoid  fever  these  conditions  arise  in  conse- 
quence of  internal  rather  than  external  gangrene,  cannot  influence  the 
indications  for  treatment. 

Many  cases,  however,  require  no  stimulation  throughout  the  whole 
course  of  the  attack;  a  smaller  number  demand  it  in  the  last  da^'s  of 
convalescence;  while  still  fewer,  and  these  are  of  the  most  severe  charac- 
ter, call  for  the  alcoholic  preparations  in  greater  or  less  abundance  from 
the  middle  of  the  second  week  to  the  termination  of  the  disease,  and 
sometimes  well  on  into  convalescence.  It  is  useless  to  give  alcohol  in  the 
early  stage  of  the  disease  in  the  hope  of  anticipating  or  of  preventing  the 
occurrence  of  prostration  and  debility.  It  is  to  be  prescribed,  however, 
as  soon  as  indicated  by  the  severity  of  special  symptoms  or  the  evidences 


ENTERIC  OR  TYPHOID  FEVER.  227 

of  general  prostration.  It  is  impossible  to  lay  down  any  general  rule  as 
to  the  amount.  The  quantity  should  be  only  as  much  as  is  necessary  to 
modify  the  symptoms  for  which  it  has  been  prescribed.  The  character  of 
the  systolic  heart-sound,  the  pulse,  and  the  nervous  symptoms,  are  our 
best  guides  as  to  the  amount  and  frequency  of  its  administration.  If  the 
systolic  sound  grows  more  distinct,  the  pulse  slower  and  the  mind  clearer 
under  its  administration,  it  may  be  continued  or  even  cautiously  increased. 
If,  however,  the  action  of  the  heart  becomes  more  rapid,  the  delirium  in- 
creases, or  the  drowsiness  deepens  under  its  use,  it  is  to  be  diminished  or 
abandoned  altogether.  The  best  effects  of  alcohol  are,  in  most  instances, 
attained  by  from  four  to  eight  ounces  of  spirits,  or  by  from  a  pint  to  a 
pint  and  a  half  of  sound  claret,  light  Burgundy,  or  champagne,  in  the 
course  of  the  twenty-four  hours.  More  than  this  is  seldom  required. 
Whiskey  or  brandy  may  be  given  in  the  form  of  milk-punch  or  com- 
mingled with  water.  Under  ordinary  circumstances  an  interval  of  from 
two  to  four  hours  should  intervene  between  each  dose.  In  mild  cases, 
toward  the  close  of  defervescence,  when  the  temperature  during  remis- 
sions reaches  for  a  time  subnormal  ranges,  great  benefit  is  often  derived 
from  the  occasional  administration  of  small  amounts  of  alcohol  in  some 
form;  sherry,  either  alone  or  as  wine-whey,  is  eligible.  If  the  urine  be 
albuminous,  alcohol  is  to  be  given  with  the  utmost  caution,  and  its  effects 
upon  the  amount  and  character  of  the  secretions  must  be  carefully  inves- 
tigated at  short  intervals. 

m.  speciaij  forms  of  treatment. 

No  medicine  or  method  of  treatment  by  which  enteric  fever  can  be 
arrested  is  at  present  known.  Many  different  methods  of  treatment  have 
been  advocated,  and  innumerable  drugs  have  been  lauded,  as  exercising  a 
special  favorable  influence  upon  the  course  of  the  disease.  Bloodletting, 
emetics,  laxatives,  various  astringents,  turpentine,  have  been  at  different 
periods  regarded  as  useful  or  necessary  in  the  treatment  of  this  disease. 
Most  of  them  have  no  longer  even  a  historical  interest;  a  few  are  occa- 
sionally employed  for  special  purposes.  Quite  recently  Dr.  Pepper'  has 
advocated  the  systematic  use  of  nitrate  of  silver  in  the  treatment  of  en- 
teric fever. 

He  administers  this  drug  In  doses  of  0.010 — 0.016  gramme  (gr.  | — W 
for  an  adult — usually  in  pill;  or,  for  children,  in  solution  in  mucilage  of 
acacia,  three  or  four  times  daily  soon  after  food.  If  constipation  exist, 
extract  of  belladonna  is  given  in  combination  ;  if  there  be  a  tendency  to 
looseness,  a  small  amount  of  opium  is  added.     Dr.  Pepper  states  that,  in 

'  Remarks  on  some  Points  in  the  Treatment  of  Typhoid  Fever,  by  William  Pepper, 
M.D.  :    PhUadelphia  Medical  Times,  February  12,  1881. 


228  THE  CONTINUED  FEVEKS. 

a  long  series  of  cases  thus  treated,  and  in  which  the  most  scrupulous 
attention  to  every  detail  was  observed,  there  has  been  a  remarkable  free- 
dom from  grave  complications  and  a  most  gratifying  percentage  of  recov- 
eries (ninety-seven  per  cent.).'  Nitrate  of  silver  has  been  frequently 
employed,  in  the  past,  in  the  treatment  of  enteric  fever,^  but  never  before 
in  the  systematic  manner  advocated  by  Dr.  Pepper.  Its  action  is  pri- 
marily and  chielly  directed  against  the  intestinal  lesions. 

The  mineral  acids,  namely:  muriatic,  phosphoric,  and  sulphuric,  are 
largely  used  in  this  country.  One  or  another  of  these,  abundantly  diluted, 
and  flavored  with  lemon-syrup,  or  orange-peel  syrup,  makes  an  agreeable 
drink  ;  they  are  generally  thought  to  exercise  a  favorable  influence  upon 
the  course  of  the  disease,  and  they  should  always  enter,  as  Professor  Flint 
suggests,  into  the  treatment,  inasmuch  as  they  in  no  wise  conflict  with 
other  therapeutic  measures. 

Calomel,  at  one  time  given  because  of  its  supposed  antiphlogistic  in- 
fluence upon  the  intestinal  lesion,  has  recently  again  come  into  use  in 
Germany  in  the  treatment  of  enteric  fever.  Many  observers  agree  in  the 
statement  that,  given  occasionally  during  the  first  week,  it  not  only  favor- 
ably influences  the  course  of  the  disease,  but  that  it  has  also  a  tendency 
to  shorten  its  duration.  It  may  be  given  in  0.5  gramme  doses  (gr.  vijss.) 
on  alternate  days  during  the  first  week  ;  if  the  temperature  be  high,  this 
dose  may  be  repeated  on  successive  days.  Liebermeister  gives  three  or 
four  0.5  gramme  doses  during  the  first  twenty-four  hours  of  the  treat- 
ment. The  diarrhoea  at  first  increases,  but  soon  subsides,  and  is  after- 
ward less  troublesome.  In  most,  but  not  in  all  cases,  the  first  doses  are 
reported  to  have  been  followed  by  a  distinct  but  transient  lowering  of 
temperature.  Moderate  ptyalism  occurred  in  some  of  the  cases  in  which 
it  was  deemed  necessary  to  repeat  the  dose  on  successive  days. 

Iodine  in  the  form  of  potassium  iodide,  in  doses  of  1.3 — 4.0  grammes 
(gr.  XX. — Ix.)  during  the  twenty-four  hours,  or  of  Lugol's  solution,  gtt. 
iij. — v.,  s.  q.  s.  h.,  has  also  been  thought  to  exercise  a  special  favorable  in- 
fluence upon  enteric  fever.  Liebermeister  states  that,  in  more  than  two 
hundred  cases,  iodine  thus  employed  produced  no  marked  effect  on  the 
course  of  the  fever,  the  temperature  showed  no  important  departure  from 
the  ordinary  course,  the  intestinal  symptoms  were  but  little  modified, 
although  in  some  instances  they  seemed  to  be  slightly  improved,  the 
iodine  eruption  did  not  occur,  and  coryza  appeared  in  only  one  light  case. 
The  death-rate  in  these  cases  was,  however,  notably  lower  than  that  in 

'  It  is  to  be  regretted  that  these  cases  have  not  been  tabulated,  and  that  Dr.  Pep- 
per's paper  conveys  no  definite  information  as  to  their  character  or  severity,  or  as  to 
whether  they  occurred  in  hospital,  or  in  private  practice,  or  in  both. 

-  See  Murchison  :  The  Continued  Fevers  of  Great  Britain.  Second  edition.  Lon> 
don,  1873.     Pp.  G52,  G53. 


ENTERIC  OK  TYPHOID  FEVER.  229 

other  cases  treated  at  the  same  time,  and  in  all  respects  in  the  same  man- 
ner, with  the  exception  of  the  use  of  the  iodine.  The  following  table 
sliows  the  percentage  of  mortality,  those  cases  not  being  included  which 
proved  fatal  within  six  days  after  their  admission  to  the  hospital: 

n  -HT  T%-  J    Percentage  of 

Cases.  I.O.         Died.      Mortality. 

Treated  Hon-specifically. 335         47         13.2 

Treated  with  calomel 216  19  8.8 

Treated  with  iodine 229         25  10.9 

In  this  country  Professor  Bartholow  has  used,  apparently  with  decided 
success,  the  following  modification  of  the  iodine  treatment  : 

5.  Tinct.  iodinii 8.00  c.c.  fl.  3  ij. 

Acid,  carbolic 4.00  c.c.  fl.  3  j. 

M.      Sig. — 1  to  3  drops  three  times  a  day. 

TJie  antipyretic  treatment  consists  of  the  systematic  employment  of 
measures  to  reduce  the  temperature  of  the  body.  In  view  of  the  fact 
that  by  far  the  greater  number  of  fatal  cases  of  typhoid  fever  die  from 
the  direct  or  indirect  effects  of  the  prolonged  high  temperature,  this 
plan  of  treatment  has  much  to  recommend  it  upon  theoretical  grounds. 
The  concurrent  testimony  of  those  observers  who  have  applied  it  system- 
atically to  large  numbers  of  cases  points  to  substantial  practical  results, 
both  in  mitigating  the  severity  of  the  symptoms,  and  in  notably  reducing 
the  mortality.  The  principle  upon  which  it  is  based  is  by  no  means  new. 
From  the  earliest  days  of  medicine  the  reduction  of  the  temperature  has 
at  all  times  been  looked  upon  as  one  of  the  most  important  indications  in 
the  treatment  of  fever.  The  main  point  in  the  management  of  enteric 
fever  is  to  control  the  temperature.  The  measures  by  which  this  can  be 
accomplished  are  hydrotherapy,  quinine,  the  salicylates,  and  digitalis. 
These  are  capable  of  depressing  the  temperature  for  a  more  or  less  ex- 
tended period;  their  systematic  employment  in  such  a  manner  as  to  con- 
trol the  febrile  movement  throughout  the  attack  constitutes  what  is 
technically  known  as  the  antipyretic  treatment. 

The  cold-water  treatment  was  first  systematized  by  Dr.  James  Currie, 
of  Liverpool  (1797),  who  used  it  in  febrile  affections,  according  to  certain 
clear  indications. 

He  employed,  as  a  rule,  cold  affusions,  frequently  repeated,  and  occa- 
sionally cold  baths.  His  method  was  adopted  by  many  physicians,  and 
soon  came  into  extensive  use  both  in  England  and  on  the  continent,  in 
the  treatment  of  many  febrile  affections,  and  especially  in  the  manage- 
ment of  typhus  and  typhoid  fever,  and  scarlatina.  It  gradually  fell  into 
neglect  and  was  for  a  long  time  almost  forgotten.     The  cold-water  treat- 


230  THE    CONTINUED    FEVERS. 

ment  of  fevers  was  revived  by  Dr.  Ernst  Brand,  of  Stettin  (1868),  and 
rapidly  came  into  use  in  Germany,  Austria,  and  Switzerland. 

The  methods  of  hydrotherapy  are  various.  Cold  water  may  be  so  ap- 
plied as  to  reduce  the  temperature,  by  means  of  the  cold  bath,  the  gradu- 
ated bath,  cold  affusions,  cold  packing,  cold  compresses,  and  cold  sponging. 
These  methods  vary  in  their  effects,  and  different  methods  are  applica- 
ble to  special  cases  ;  but  that  one  of  them  is  to  be  preferred  by  which 
the  desired  end  is  reached  with  the  least  inconvenience  to  the  patient. 

Tlie  cold  hath  is,  for  general  use,  not  only  the  most  effective,  but  it  is 
also  the  least  troublesome  to  apply.  The  following  is  the  plan  employed 
by  Liebermeister  at  Basle;  it  differs  but  little  from  that  generally  in 
vogue  elsewhere  upon  the  continent,  and  that  now  practised  by  Dr.  Cay- 
ley  in  London.  I  am  not  aware  that  the  treatment  of  enteric  fever  by 
cold  bathing  has  been  practised  with  the  same  degree  of  system  and 
vigor,  and  upon  an  extended  scale,  by  any  observer  in  America. 

"  For  adult  patients  the  full-length  cold  bath,  of  20°  C.  (68°  F.)  is  to 
be  prepared.  The  same  water  can  be  used  for  several  successive  baths 
for  the  same  patient;  the  bath-tub  remains  standing  full,  and  the  water, 
representing  about  the  temperature  of  the  room,  answers  the  purpose 
without  change.  The  duration  of  the  bath  should  be  about  ten  minutes. 
If  prolonged  much  beyond  that,  it  becomes  unpleasant  to  the  patient, 
and  may  even  prove  injurious  to  him.  If  feeble  persons  are  much  affected 
by  the  bath,  remaining  cold  and  collapsed  for  a  long  time,  the  duration 
should  be  reduced  to  seven  or  even  to  five  minutes.  A  short,  cold  bath 
like  this,  will  have  a  much  better  effect  than  a  longer  one  of  lukewarm 
water.  Immediately  after  the  bath  the  patient  should  have  rest;  he  is, 
therefore,  to  be  wrapped  up  in  a  dry  sheet  and  put  to  bed.  (The  bed 
may  with  advantage  be  warmed,  especially  at  the  foot.)  He  should  be 
lightly  covered  and  given  a  glass  of  wine.  With  very  feeble  patients  it 
is  well  to  begin  with  baths  of  a  higher  temperature,  say  24°  C.  (75°  F.); 
but  a  less  decided  effect  will  follow.  In  such  cases  the  method  of  Ziems- 
sen  is  to  be  especially  recommended,  if  the  surroundings  permit.  A  bath 
of  'do°C  (95°  F.)  is  at  first  employed;  cold  water  is  gradually  added 
until  the  temperature  of  the  bath  is  reduced  to  22.2°  C.  (72°  F.),  or  be- 
low.    These  baths  should  be  of  longer  duration." 

In  severe  cases  the  temperature  is  taken  every  two  hours,  day  and 
night.  As  soon  as  39.5*^  C.  (103.1^  F.)  in  the  rectum,  or  39°  C.  (102.2° 
F.)  in  the  axilla,  is  reached,  the  bath  is  given.  Individual  peculiarities 
are  to  be  regarded.  It  may  be  advisable  to  give  the  bath  before  the  tem- 
perature runs  qtiite  up  to  the  heights  above  mentioned,  or  to  give  a  bath 
of  shorter  duration,  or  of  warmer  temperature,  or  the  gradually  reduced 
bath  of  Ziemssen. 

The  aim  of  this  plan  of  treatment  is  to  keep  the  temperature  during 
the  whole  course  of  the  disease  within  the  bounds  of  a  moderate  fever 


ENTERIC    OR   TYPHOID    FEVEIi.  231 

heat.  This  cannot  be  accomplished  by  one  bath  or  by  a  few  baths.  If 
the  treatment  be  systematically  carried  out,  from  four  to  eight  baths  in 
the  course  of  twenty-four  hours  will  in  ordinary  cases  be  necessary.  In 
very  severe  cases  Liebermeister  has  repeated  the  baths  every  two  hours, 
so  that  twelve  baths  have  been  given  every  twenty-four  hours,  and  in 
some  instances  the  number  of  baths  required  by  a  patient  during  his  en- 
tire illness  has  exceeded  200.  Each  bath  ought  to  cause  a  reduction  of 
temperature  of  1°— 1.66°  C.  (2°— 3°  F.).  If  the  temperature  be  not  modi- 
fied to  this  extent,  the  following  baths  should  be  colder  or  longer.  It  is 
not  necessary  to  take  the  temperature  in  the  bath,  for  the  reason  that  it 
continues  to  fall  for  some  time  afterward;  it  should  be  taken  about  half 
an  hour  after  the  removal  of  the  patient  from  the  bath.  In  children  the 
baths  may  be  made  warmer  and  of  shorter  duration.  In  cases  marked 
by  great  nervous  depression  with  only  a  moderate  elevation  of  tempera- 
ture, cold  baths  of  short  duration,  or  cold  affusions,  are  recommended  for 
their  stimulating  effect  on  the  nervous  system. 

The  graduated  bath  is  particularly  useful  in  the  treatment  of  children, 
and  where  the  cold  baths  are  inadmissible,  as  in  aged  persons,  or  those 
suffering  from  disease  of  the  heart  or  lungs,  and  in  cases  of  extreme  pros- 
tration. 

Cold  affusion  is  regarded  by  the  advocates  of  the  antipyretic  treat- 
ment as  of  inferior  value  in  reducing  temperature.  It  is,  however,  more 
pleasant  to  the  patient,  and  may  be  employed  in  cases  where  baths 
are  inadmissible,  or  where  a  stimulating  effect  upon  the  nervous  system 
is  desired. 

Cold  packs  are  also  inferior  to  bathing  as  a  means  of  reducing  tem- 
perature. They  are  usually  well  borne  even  by  feeble  patients,  and  are 
particularly  applicable  in  the  treatment  of  children,  to  whom  they  may 
take  the  place  of  baths.  They  are  very  troublesome  to  apply.  The  bed 
being  protected  by  a  gum  cloth,  the  patient  is  thoroughly  wrapped  in 
a  sheet  wrung  out  of  cold  water,  the  face  and  feet  alone  being  left  free; 
he  is  then  lightly  covered  with  a  blanket.  A  course  of  four  consecutive 
packs,  of  ten  to  twenty  minutes'  duration  each,  is  said  to  be  about  equiva- 
lent in  its  effect  upon  the  temperature  to  a  single  cold  bath  of  tea 
minutes. 

Cold  compresses  give  rise  to  local  lowering  of  temperature,  but  have 
no  great  influence  on  the  general  heat  of  the  body. 

Cold  sponging  has  but  little  influence  upon  the  internal  temperature; 
it  therefore  cannot  be  regarded  as  entering  into  the  antipyretic  treat- 
ment, properly  so  called.  It  is  useful  for  purposes  of  cleanliness,  and  is 
in  most  instances  grateful  to  the  patient.  I  am  in  the  habit  of  ordering 
my  patients  sponged  two  or  three  times  daily  with  water  containing  aro- 
matic vinegar. 

Among  the  more  important  contraindications  to  the  antipyretic  treat' 


232  THE  CONTINUED  FEVERS. 

ment,  and  in  particular  to  tlie  cold  baths,  are  hemorrhage  from  the  bowels, 
great  feebleness  of  the  circulation,  and  coldness  of  the  extremities  and 
surface  of  the  body,  with  high  internal  heat.  This  method  of  treatment 
is  also  inadmissible  in  subjects  advanced  in  years,  and  in  those  suffering 
from  chronic  bronchitis,  pulmonary  emphysema,  and  organic  disease  of 
the  heart.  Dr.  Cayley  does  not  regard  albuminuria  as  a  contraindica- 
tion. 

Among  the  medicines  capable  of  reducing  the  temperature  of  the 
body,  quinine  occupies  the  first  place.  In  order  to  secure  its  full  effect 
it  must  be  given  in  large  doses.  It  is  useless  to  give  small  doses  at  con- 
siderable intervals.  From  1.3  to  2.G  grammes  (gr.  xx. — xl.)  are  necessary 
to  produce  a  decided  fall  of  temperature  in  an  adult.  This  amount  should 
be  administered  within  the  space  of  an  hour,  0.5  gramme  (gr.  vijss.)  being 
given  every  ten  minutes  until  the  full  dose  is  taken.  A  decline  of  1.6° — 
2.2°  C.  (3° — 4°  F.)  usually  follows  in  the  course  of  from  six  to  twelve 
hours.  As  the  effects  of  the  medicine  pass  off,  the  temperature  gradually 
rises  again,  but  does  not  usually  attain  its  original  height  until  the  expi- 
ration of  twenty-four  hours.  It  is  best  given  at  night,  some  time  after 
the  evening  exacerbation  has  reached  its  height,  as  the  effects  are  more 
marked  upon  a  falling  than  upon  a  rising  temperature.  It  may  be  ad- 
ministered in  powder  or  in  solution,  and  should  be  followed  by  small 
amounts  of  hot  broth.  If  vomiting  occur,  quinine  may  be  administered 
in  small  enemata  along  with  opium.  Symptoms  of  cinchonism  usually 
follow,  but  they  are  less  marked  than  after  similar  doses  in  afebrile  dis- 
eases or  in  health.  Among  the  more  constant  effects  of  large  doses  of 
quinine  is  profuse  sweating. 

The  salicylates,  given  in  large  doses — 4.0 — 6.9  grammes  (gr.  Ix. — cv.) 
in  the  course  of  twenty-four  hours — rapidly  and  powerfully  depress  the 
temperature.  Sodium  salicylate  has  come  largely  into  use  in  the  treat- 
ment of  typhoid  fever  in  Germany.  Its  administration  in  large  doses  is 
sometimes  followed  by  gastric  disturbances,  increase  of  diarrhoea,  and  a 
tendency  to  hemorrhage.  It  also  appears  to  exert  an  unfavorable  influ- 
ence upon  the  kidneys,  occasionally  manifested  by  an  increased  tendency 
to  albuminuria.  The  chief  objection  to  this  medicine  relates  to  its  de- 
pressing effects  upon  the  circulation. 

Digitalis,  administered  in  full  doses,  is  also  capable  of  depressing  the 
temperature  in  typhoid  fever.  For  this  purpose  0.666 — 1.3  grammes  (gr. 
X. — XX.)  are  recommended  to  be  given  in  divided  doses  extended  over  a 
period  of  about  thirty-six  hours,  and  followed  by  a  full  antipyretic  dose 
of  quinine.  By  this  procedure  a  complete  intermission  can  be  produced, 
even  in  severe  and  obstinate  cases,  where  quinine  alone  has  but  little 
effect  upon  the  temperature.  Digitalis,  both  in  substance  and  in  the 
form  of  the  infusion,  is  often  badly  borne  by  the  stomach;  it  is  inadmis- 
sible where  the  action  of  the  heart  is  feeble,  the  rule  for  its  administra- 


ENTERIC    Oli   TYPHOID    FEVER.  233 

tion  In  enteric  fever  being  exactly  opposite  to  that  which  regulates  its 
use  in  the  treatment  of  organic  diseases  of  the  heart. 

The  advocates  of  the  antipyretic  treatment  of  enteric  fever  claim  that 
under  its  use  not  only  is  the  mortality  greatly  reduced,  but  that,  to  use 
the  words  of  Liebermeister,  the  entire  appearance  and  bearing  of  patients 
is  such  that  the  old  picture  of  a  typhoid  fever  patient  is  no  longer  to  be 
seen,  and  that  the  disease  has  in  fact  lost  a  great  part  of  its  terrors. 
This  observer  informs  us  that,  in  the  hospital  at  Basle,  there  were  treated 
upon  the  expectant  plan,  between  1843  and  1864,  1,718  cases  of  typhoid 
fever;  of  these  469,  or  27.3  per  cent.,  proved  fatal.  From  1865  to  Septem- 
ber, 1866,  there  were  treated,  under  an  incomplete  antipyretic  plan,  982 
patients;  of  these  159,  or  16.2  per  cent.,  died.  Between  September,  1866, 
and  1872,  there  were  treated,  by  the  antipyretic  plan  systematically  car- 
ried out,  1,121  cases;  of  these  92,  or  8.2  per  cent.,  died.  After  the  elimi- 
nation of  certain  errors  in  these  statistics,  he  concludes  that  the  mortality 
under  the  antipyretic  treatment  is  ten  or  eleven  per  cent,  against  a  mor- 
tality of  twenty-five  or  thirty  per  cent,  under  the  expectant  plan.  In  the 
hospital  at  Kiel,  the  mortality  under  the  antipyretic  plan,  as  pursued  by 
Jurgensen,  was  3.1  per  cent.;  that  under  the  expectant  plan,  between  the 
years  1850  and  1861,  was  15.4  per  cent.  In  the  military  hospital  at  Stet- 
tin, the  mortality  under  the  antipyretic  plan  was  4  per  cent.;  under  the 
expectant  plan,  25.6  per  cent. 

Dr.  Brand  found  that,  of  8,141  cases  treated  antipyretically,  600  died, 
making  a  mortality  of  7.4  per  cent. 

In  by  far  the  greater  number  of  enteric  fever  cases,  as  the  disease  is 
known  to  American  physicians,  the  systematic  antipyretic  treatment,  by 
means  of  cold  baths,  is  clearly  unnecessary  by  reason  of  the  mildness  of 
the  pyrexia;  in  many  others  it  is  clearly  inadmissible,  and  in  all  cases  it 
is  difficult  of  application,  requiring  a  degree  of  attention  and  a  number 
of  trained  assistants  not  always  available  in  hospitals,  scarcely  ever  to  be 
secured  in  private  practice.  To  these  causes  is  doubtless  largely  due  the 
fact  that  it  has  not  come  into  use  to  any  considerable  extent  in  this  coun- 
try. Prejudice  in  the  minds  of  the  people,  and  perhaps  also  among 
medical  men,  contributes  to  the  opposition  to  this  method  of  treatment. 
Even  the  suggestion  of  a  modified  antipyretic  treatment,  necessary  to 
save  life,  too  often  encounters  the  decided  opposition  of  the  friends  of  the 
patient,  who  look  upon  cold  compresses,  the  pack,  or  the  douche,  as  add- 
ing to  the  horrors  of  the  situation.  ]\Ioreover,  those  physicians  who  are 
favorably  impressed  with  the  accounts  of  this  treatment  and  its  results, 
enter  into  half-way  measures  at  a  late  period  of  the  disease,  without  the 
energy  and  enthusiasm  necessary  to  the  realization  of  its  best  effects. 

With  reference  to  the  reduction  of  temperature  by  means  of  drugs, 
and  especially  by  means  of  large  doses  of  quinine,  the  way  is  clearer,  and 


234  THE  CONTINUED  FEVERS. 

this  practice  is  growing  in  favor  in  America.  For  my  own  part,  I  look 
upon  large  doses  of  quinine,  at  intervals  of  forty-eight  to  seventy-two 
hours,  as  an  essential  part  of  the  management  of  all  cases  iu  which  the 
evening  temperature  rises  above  40°  C.  (104°  F.). 

IV,    THE  KXPECTANT  TREATMENT. 

The  expectant  or  rational  treatment  of  enteric  fever  is  that  generally 
employed  at  the  present  time.  Notwithstanding  the  diminished  mortality 
following  the  employment  of  the  antipyretic  treatment  in  Germany,  it 
has  never  been  generally  introduced  in  France,  Great  Britain,  or  the 
United  States,  and  the  physicians  of  these  countries  for  the  most  part 
still  adhere  to  the  expectant  or  the  modified  expectant  plan.  This  method 
of  treatment  is  based  upon  the  knowledge  that  enteric  fever,  like  the 
other  acute  infectious  diseases,  is  of  definite  duration  and  cannot  be  cut 
short,  that  is  to  say,  cured,  by  therapeutic  measures.  The  patient,  once 
having  become  the  subject  of  the  infection,  must  pass  through  the  suc- 
cessive stages  of  the  fever  before  he  regains  his  health.  If  then  life  can 
be  maintained  for  a  definite  time  and  no  serious  complication  or  sequel 
remains,  recovery  will  take  place.  The  patient  is  to  be  carefully  watched, 
he  is  to  be  placed  under  the  most  favorable  hygienic  conditions,  disturb- 
ing and  injurious  influences  are  to  be  prevented  or  removed,  and  efforts 
are  to  be  made  to  combat  unfavorable  symptoms  and  to  avert  complica- 
tions. The  successful  management  of  enteric  fever  upon  this  plan  pre- 
supposes on  the  part  of  the  physician  an  intimate  knowledge  of  the  course 
of  the  disease,  of  the  relative  importance  of  the  symptoms,  of  the  order 
of  their  appearance  and  their  duration,  and  a  familiarity  with  the  ana- 
tomical lesions,  the  connection  between  the  lesions  and  symptoms,  and 
the  complications  that  are  likely  to  arise. 

Absolute  rest  in  bed,  intelligent  and  careful  nursing,  a  restricted  diet, 
cleanliness  of  the  person  and  the  bedding,  and  ventilation,  form  the  basis 
of  the  treatment.  "  If,"  in  the  words  of  Jenner,  the  most  able,  as  well 
as  the  most  recent  advocate  of  this  method,  "  medicinal  in  addition  to 
hygienic  treatment  is  required,  it  is  because  special  symptoms  by  their 
severity  tend  directly  or  indirectly  to  give  an  unfavorable   course  to  the 

disease My  experience  has  impressed  on  me  the  conviction 

that  that  man  will  be  the  most  successful  in  treating  typhoid  fever 
who  watches  its  progress,  not  only  with  the  most  skilled  and  intelligent, 
but  also  with  the  most  constant  care,  and  gives  unceasing  attention  to 
little  things,  and  who,  when  prescribing  an  active  remedy,  weighs  with 
the  greatest  accuracy  the  good  intended  to  be  effected  against  the  evil 
the  prescription  may  inflict,  and  then,  if  the  possible  evil  be  death,  and 
the  probable  good  short  of  the  saving  of  life,  holds  his  hand." 

The  special  symptoms  that  are  apt  to  give  an  unfavorable  course  to 


ENTERIC    OR   TYPHOID    FEVER.  235 

the  disease  are  to  be  treated  for  the  most  part  in  accordance  with  the 
general  principles  of  therapeutics.  Some  of  the  symptoms,  complications, 
and  sequels  are  best  managed  in  accordance  with  the  following  rules  of 
practice: 

V.   THE  TKEATMENT  OF   SPECIAIi  SYMPTOMS,    COMPIiICATIONS,   AND  SEQUELS. 

Headache  occasionally  causes  the  patient  considerable  distress  in  the 
early  days  of  the  attack.  It  generally  requires  no  special  treatment,  and 
subsides  spontaneously  about  the  middle  of  the  second  week  of  the  dis- 
ease. Absolute  quiet,  darkening  of  the  room,  and  local  applications, 
sometimes  cold,  sometimes  warm,  are,  as  a  rule,  all  that  is  necessary  to 
control  it. 

Sleeplessness  is  occasionally  an  important  symptom  in  the  early  stages 
of  the  disease.  Like  the  headache,  it  commonly  disappears  or  diminishes, 
without  special  treatment,  some  time  during  the  course  of  the  second  week. 
This,  however,  is  not  always  the  case.  Sleeplessness  is  occasionally  per- 
sistent and  exhausting.  It  then  becomes  necessary  to  treat  it.  During 
the  primary  fever  potassium  bromide  and  chloral  yield  the  most  satis- 
factory results.  They  may  be  used  either  in  combination  or  separately. 
In  the  personal  experience  of  the  writer,  chloral  alone,  in  moderate  doses, 
has  proved  adequate  to  overcome  this  symptom  in  most  cases,  and  its 
administration  has  been  unattended  by  cardiac  depression  or  other  un- 
favorable effects. 

If  other  hypnotics  fail,  opium  in  sufficient  doses  will  secure  sleep. 
This  drug  and  its  preparations,  in  doses  sufficient  to  induce  sleep,  must 
be  regarded  as  objectionable  during  the  early  stages  of  the  disease,  on  ac- 
count of  its  unfavorable  influence  upon  digestion  and  the  secretions — an 
influence  not  wholly  obviated  by  the  hypodermic  use  of  morpliia.  After 
the  middle  of  the  second  week,  that  is  to  say,  during  the  secondary  fever, 
opium  becomes  at  once  our  most  efficient  and  safest  means  of  controlling 
prolonged  sleeplessness  and  excitability,  and  its  use  in  fever  dependent 
upon  gangrene  and  sloughing  is  in  accordance  with  well-established  prin- 
ciples of  surgery.  In  the  later  stages  of  the  disease,  chloral  is,  by  reason 
of  its  depressing  influence  upon  the  circulation,  even  more  objectionable 
than  is  opium  in  the  early  stages. 

Somnolence,  stupor,  and  delirium,  are  to  be  treated  by  stimulants  and 
the  abstraction  of  bodily  heat.  In  the  treatment  of  these  symptoms, 
alcohol  stands  first  and  almost  alone  among  the  stimulants  ;  spirits  of 
chloroform  and  camphor  are  of  use  ;  am,monium  carbonate  is  of  inferior 
value,  and  has  been  objected  to  on  theoretical  grounds,  as  being  liable  to 
increase  the  alkalinity  of  the  blood.  It  is  frequently  used  in  the  treat- 
ment of  pulmonary  complications.  If  delirium  continue  or  coma  threaten, 
great  benefit  is  often  derived  from   the  local   application  of  cold  to  the 


236  THE  conti:nued  fevers. 

head,  by  means  of  either  the  cold  douche,  or  an  ice-cap.  If  the  brain- 
symptoms  are  specially  severe,  the  head  may  be  shaved,  and  blisters  may 
be  applied  to  tlie  nape  of  the  neck  or  to  the  temples  ;  these  measures 
are  of  doubtful  value,  and  are  only  to  be  resorted  to  in  desperate  cases. 
The  lighter  forms  of  disturbance  of  the  functions  of  the  brain,  as  somno- 
lence and  transient  delirium,  do  not  call  for  special  measures  of  treatment. 
They  are  often  relieved,  to  some  extent,  by  coffee. 

Tremor  is  an  important  symptom.  It  indicates  extreme  prostration. 
Sir  William  Jenner  has  called  attention  to  the  fact  that  tremor,  out  of  all 
proportion  to  the  other  signs  of  nervous  prostration,  is  to  be  looked 
upon  as  a  sign  of  deep  ulceration  of  the  intestines.  A  small,  deep  slough, 
the  separation  of  which  is  especially  liable  to  give  rise  to  intestinal  hemor- 
rhage or  perforation,  will  often  occasion  great  tremor.  Tremor  of  this 
kind  is  to  be  treated  with  full  doses  of  alcohol  and  opium,  not  only  for 
their  general  effect  upon  the  nervous  system,  but  also  with  a  view  to  their 
local  effects  in  limiting  sloughing  and  ulceration. 

Dryness  of  the  tongue,  and  the  accumulation  of  sordes  upon  the  teeth 
and  gums,  are  to  be  obviated  by  the  frequent  administration  of  fluids  or 
by  pieces  of  ice  allowed  to  dissolve  in  the  mouth.  The  patient,  if  able 
to  do  so,  should  rinse  his  mouth  frequently  with  pure  water,  or  water 
containing  small  quantities  of  claret,  aromatic  vinegar,  or  tincture  of 
myrrh. 

Diarrhoea,  so  long  as  the  stools  are  of  moderate  amount  and  do  not 
exceed  in  number  three  or  four  in  the  course  of  twenty-four  hours,  does 
not  call  for  special  treatment.  If,  however,  the  passages  are  copious  or 
very  frequent,  the  strength  of  the  patient  is  endangered,  and  it  becomes 
necessary  to  control  them.  Sometimes  diarrhoea  is  due  to  errors  in  diet, 
such  as  the  use  of  solid  food,  or  of  excessive  amounts  of  food,  particularly 
milk  and  the  strong  animal  broths,  and  abates  upon  the  correction  of  such 
errors.  It  may  arise  in  consequence  of  the  patient's  drinking  excessive 
amounts  of  fluid,  which  passes  through  the  bowel  without  being  absorbed, 
and  stimulates  excessive  secretion  from  the  intestinal  mucous  membrane 
(Jenner).  In  the  absence  of  these  causes,  diarrhoea  is  to  be  attributed  to 
catarrhal  inflammation  of  the  intestinal  mucous  membrane.  It  is  best 
treated  by  hism,uth  carbonate  or  siibnitrate,  in  large  doses,  1.3  gramme 
(gr.  XX.)  s.  q.  quarta  vel  sexta  horii.  To  these  powders  may  be  added,  if 
necessary,  opium  in  0.01 — 0.016  gramme  (gr.  \ — \)  doses,  or  deodor- 
ized laudanum  \xv  doses  of  from  three  to  five  drops.  Other  astringents, 
such  as  alum,  sugar  of  lead,  nitrate  of  silver,  tannin,  catechu,  and  kino, 
either  alone  or  in  combination  with  opium,  are  recommended  for  the 
control  of  the  diarrhoea.  It  is  more  sati^actory  at  the  bedside  to  use 
one  or  two  efficient  remedies,  than  to  resort  to  a  number  of  uncertain 
drugs;  and  in  bismuth  freely  given,  or  in  opium  in  repeated  small  doses, 
either  by  the  mouth  or  by  enema,  or  in  these  two  remedies  combined,  will 


ENTEEIC  OR  TYPHOID  FEVER.  237 

be  found,  in  almost  all  cases,  an  efficient  medication  ag-ainst  excessive 
diarrhoea  in  enteric  fever. 

If  the  stools  be  fetid  or  highly  ammoniacal,  Jenner  recommends  the 
occasional  administration  of  a  teaspoonful  of  charcoal — animal  charcoal 
being  preferred,  and  care  being  taken  that  it  is  in  impalpable  powder. 
Creosote  and  carbolic  acid  are  also  of  service. 

Constipation  occasionally  occurs.  If  it  be  but  slight,  it  is  often  due 
to  the  absence  of  extensive  intestinal  lesions  and  the  catarrhal  inflamma- 
tion with  which  such  lesions  are  associated.  Hence,  in  mild  cases  slight 
constipation  requires  no  treatment  beyond  the  occasional  administration 
of  small  doses  of  calomel  or  castor-oil,  or  the  juice  of  an  orange.  Con- 
stipation may,  however,  be  due  to  torpidity  of  the  large  intestine,  the 
fecal  matter  being  retained  for  a  long  time  and  the  stools  being  hard 
and  dry.  Under  these  circumstances  a  sort  of  secondary  diarrhoea,  due 
to  irritation  of  the  lower  bowel  by  the  retained  fecal  matter,  may  arise. 
This  form  of  diarrhoea  is  attended  with  a  feeling  of  local  distress  and 
tenesmus,  which  are  unusual  in  enteric  fever,  and  will  be  promptly  re- 
lieved by  the  removal  of  its  cause.  Prolonged  constipation  is  by  no 
means  to  be  taken  as  an  indication  of  moderate  intestinal  lesions;  on 
the  contrary,  deep  ulceration  of  one  or  more  of  Peyer's  patches  is  not 
only  frequently  associated  with  constipation,  but,  by  its  paralyzing  in- 
fluence upon  the  intestine,  it  is  very  often  the  cause  of  constipation. 
Aperients  administered  by  the  mouth  are  therefore  to  be  shunned,  lest 
by  inducing  peristalsis  they  forcibly  detach  a  deep  slough,  or  otherwise 
mechanically  give  rise  to  perforation  where  the  sloughing  extends  to,  or 
implicates  the  serous  coat  of  the  intestine.  Large  enemata  are  also  at- 
tended with  danger  arising  from  their  liability  to  set  up  energetic  peri- 
staltic movements,  which  may  extend  to  the  lower  part  of  the  ileum.  The 
constipation  of  enteric  fever  is  most  safely  and  satisfactorily  treated  by 
the  daily  administration  of  small  enemata  of  strong,  warm  soap-suds  or 
of  thin  gruel. 

Tympany  is  present  to  a  greater  or  less  extent  in  almost  all  cases. 
It  may  be  due  to  deficient  power  of  expulsion,  or  to  an  undue  generation 
of  gas  in  the  intestine,  and  reaches  its  maximum,  as  a  general  rule,  during 
the  latter  part  of  the  third,  or  in  the  fourth  week  of  the  fever  ;  for  at  this 
period  the  causes  that  produce  it  are  fully  developed.  These  causes  are: 
first,  sloughing  and  ulceration  of  the  intestine,  which  in  itself,  if  deep,  is 
sufficient  to  cause  paralysis;  second,  general  prostration  leading  to  defi- 
cient contraction  alike  of  the  intestinal  walls  and  of  the  abdominal  mus- 
cles; and  third,  alteration  in  the  character  of  the  digestive  fluids,  which, 
no  longer  possessing  the  antiseptic  properties  of  health,  permit  the  speedy 
decomposition  of  the  intestinal  contents.  Flatus  accumulates  in  part  in 
the  small  intestine,  but  chiefly  in  the  colon;  it  varies  from  an  amount 
scarcely  greater  than  that  of  health  to  enormous  abdominal  distention, 


238  THE  CONTINUED  FEVERS. 

interfering  with  the  play  of  the  diaphragm,  and,  by  the  outward  pressure 
of  the  accumulated  gas  within  the  gut,  adding  to  the  danger  of  perfora- 
tion. The  indications  for  the  treatment  of  this  symptom  are  twofold; 
the  first  have  reference  to  the  loss  of  nerve-energy,  and  call  for  increased 
stimulation.  The  second  have  reference  to  the  nature  of  the  food,  and 
the  arrest  of  the  gas-generating  decomposition  of  the  intestinal  contents. 
Thus,  alcohol  is  to  be  given,  or,  if  already  employed,  the  amount  is  to  be 
increased.  Turpentine,  campJior,  and  minnte  doses  of  opium  may  be 
added  to  the  treatment;  the  abdomen  should  be  gently  rubbed  with  the 
hand  alone,  or  with  turpentine,  at  short  intervals,  or  turpentine  stupes 
may  be  applied.  Charcoal  is  to  be  administered  with  a  view  of  prevent- 
ing decomposition  of  the  intestinal  contents,  and  only  such  food  is  to  be 
given  as  will  probably  leave  little  or  no  residue  to  undergo  decomposi- 
tion in  the  intestine.  At  the  same  time  pepsin  is  to  be  administered 
along  with  the  mineral  acids.  If  the  amount  of  flatus  in  the  large  in- 
testine be  excessive,  paralysis  from  over-distention  may  arise.  It  may 
then  become  necessary  to  carefully  introduce  into  the  bowel  an  oesopha- 
geal tube  with  a  view  of  mechanically  removing  a  portion  at  least  of  the 
accumulated  gas. 

If  constipation  coexist  with  tympany  it  is  to  be  relieved  by  the  ad- 
ministration of  small  enemata,  such  as  have  been  described  above,  or  with 
the  addition  of  turpentine,  once  or  twice  a  day.  Suddenly  developing 
tympany  is  sometimes  a  symptom  of  peritonitis. 

Intestinal  hemorrhage,  if  it  be  slight,  does  not  call  for  other  meas- 
ures of  treatment  than  the  most  absolute  rest  of  the  patient,  the  restric- 
tion of  his  diet  to  substances  capable  of  being  most  readily  digested  and 
absorbed  in  the  stomach  and  upper  intestine,  such  as  essence  of  meat  in 
small  doses,  wine-whey,  koumiss,  etc.,  and  opium  in  moderate  doses,  either 
by  the  mouth  or  by  enemata.  Food  and  drink  are  to  be  iced,  and  lumps 
of  ice  held  in  the  mouth  and  swallowed.  The  action  of  the  bowels  is  to 
be  as  far  as  possible  controlled. 

If  the  loss  of  blood  be  profuse,  the  danger  becomes  imminent,  and  more 
active  measures  are  to  be  promptly  resorted  to.  In  addition  to  opium, 
the  remedies  to  be  mainly  relied  upon  are  gallic  acid,  turpentine,  and  ergot. 

Murchison  states  that  in  his  practice  the  following  mixture  was,  dur- 
ing many  years,  almost  invariably  successful  for  arresting  the  bleeding: 

]^.  Acid,  tannic 0.66  grm.  gr.  x. 

Tinct.  opii 0.66  c.c.  TTl  x. 

Spirit,  terebinth 0.99  TH,  xv. 

Mucilag 8.00  3  i j. 

Tinct.  chloroform 1.33  TH  xx. 

Aq.  menth.  pip ad.  33  |  j. 

M.  ft.  haust.  s.  q.  s.  h. 


ENTERIC  OR  TYPHOID  FEVER.  239 

ErgoUne,  may  be  injected  hypodermically  in  doses  of  0.6G  grm,  (gr.  x.) 
at  intervals  of  half  an  hour  or  an  hour,  until  the  evidences  of  bleeding 
cease.  An  ice-bag  or  bladder,  filled  with  broken  ice  mixed  with  bran,  is 
to  be  applied  to  the  abdomen.  It  is  not  to  be  hoped  that  any  direct  local 
effect  upon  the  intestinal  lesions  will  follow  the  use  of  the  astringent  pre- 
parations of  iron  either  by  the  mouth  or  by  the  rectum. 

Peritonitis,  whether  due  to  perforation  of  the  intestine  or  to  other 
causes,  calls  for  the  free  administration  of  opium.  To  an  adult,  as  much 
as  0.133  gramme  (gr.  ij.)  may  be  given  at  once,  followed  by  half  that 
amount  every  second  or  third  hour  until  moderate  stupor  is  produced. 
For  at  least  a  time  no  nourishment,  excepting  concentrated  meat-juices, 
a  spoonful  at  a  time,  and  brandy  and  water  in  not  larger  amounts,  is  to 
be  administered.  The  abdomen  may  be  smeared  with  a  mixture  of  equal 
parts  of  sweet  oil,  laudanum,  and  turpentine,  or  warm  fomentations  or 
turpentine  stupes  may  be  applied  to  it.  Better  than  these,  however,  is 
the  application  of  large,  thinly  spread  mush  or  flaxseed  poultices  well 
smeared  with  lard.     The  Germans  recommend  ice-bags  and  ice-poultices. 

If  opium  be  not  well  borne  by  the  stomach,  morphia  is  to  be  adminis- 
tered hypodermically.  Should  the  patient's  life  be  prolonged,  it  is  of  the 
utmost  importance  that  the  bowels  be  confined  as  long  as  it  is  possible  to 
keep  them  so.  In  most  cases  a  movement  will  take  place  at  the  end  of 
several  days,  even  under  the  continued  use  of  opium;  otherwise,  after  all 
evidences  of  peritonitis  have  subsided,  small,  lukewarm  enemata  may  be 
cautiously  employed. 

In  enteric  fever  palpation  of  the  abdomen  is  to  be  practised  with 
great  caution,  on  account  of  the  danger  of  exciting  peritonitis,  of  causing 
perforation,  or  of  rupturing  the  spleen. 

The  suprapubic  region  is  to  be  examined  by  palpation  and  percussion 
twice  daily  as  a  matter  of  routine,  and  whenever  necessary  the  catheter 
is  to  be  employed. 

Frequent  exploration  of  the  chest  by  the  methods  of  physical  diagno- 
sis is  necessary;  complications  capable  of  determining  a  fatal  result  may 
be  arrested  by  the  prompt  detection  and  treatment  of  pulmonary  lesions 
attended  by  insignificant  subjective  symptoms. 

Hypostatic  congestion  is  to  be  prevented  by  guarding  against  the 
heart-failure  to  which  it  is  chiefly  due.  The  control  of  temperature  and 
the  use  of  stimulants  constitute  the  most  important  means  to  this  end. 
Digitalis  is  a  dangerous  remedy  in  the  feebleness  of  the  heart  due  to  the 
acute  granular  degeneration  occurring  in  the  continued  fevers,  and  is  to 
be  administered  with  great  caution.  The  patient's  position  is  to  be 
changed  from  time  to  time,  with  a  view  of  preventing  hypostasis,  and  he 
is  to  be  histructed  to  occasionally  take  three  or  four  deep  inspirations.  If 
congestion  occur,  the  occasional  application  of  turpentine  stupes  to  the 
chest  is  of  great  advantage. 


240  THE  CONTINUED  FEVERS. 

JDed-sores  are  to  be  prevented  by  frequent  change  of  position,  and 
the  removal  of  pressure  by  means  of  cold-water  bags  or  air-cushions. 
Scrupulous  cleanliness  and  care  with  regard  to  the  bed  are  important. 
So  long  as  the  skin  is  sound,  the  parts  especially  subjected  to  pressure, 
and  therefore  liable  to  gangrene,  are  to  be  frequently  bathed  with  equal 
parts  of  alcohol  and  lead-water.  If  erosions  appear  they  are  to  be  treated 
in  accordance  with  general  surgical  principles.  Bartholow  regards  a 
mixture  of  equal  parts  of  copaiba  and  castor-oil  as  the  best  dressing  for  a 
bed-sore. 

Other  complications  and  sequels  are  to  be  treated  in  accordance  with 
general  therapeutic  indications. 

VI.    THE  MANAGEMENT   OF   THE  PATIENT   DUKING   CONVALESCENCE. 

During  the  early  days  of  convalescence  the  temperature  remains  labile, 
and  abrupt  recrudescences  of  the  fever  are  apt  to  arise  from  slight  causes. 
It  is  therefore  important  that  the  patient  be  cared  for  assiduously  for 
some  time  after  defervescence  is  complete.  For  at  least  a  week,  morning 
and  evening  temperature  observations  should  be  taken;  and  during  this 
time  the  diet  is  to  be  restricted  to  milk,  eggs,  custards,  farinaceous  foods, 
light  puddings,  and  animal  broths  or  jellies.  The  visits  of  friends  are  to 
be  limited  both  in  number  and  duration.  Undue  exertion,  even  within  the 
limits  of  the  chamber,  is  to  be  carefully  guarded  against,  and  all  conver- 
sation upon  business  affairs,  or  other  matters  liable  to  give  rise  to  excite- 
ment or  to  depressing  emotions,  is  to  be  avoided.  At  the  end  of  a  week, 
solid  food,  and  particularly  meat,  may  be  resumed;  but  the  effect  of  such 
changes  of  diet  upon  the  temperature  and  general  condition  of  the  patient 
is  to  be  carefully  watched. 

The  liability  to  intestinal  hemorrhage,  perforation,  or  a  relapse,  are  to 
be  constantly  borne  in  mind,  and  for  a  long  time  the  patient's  diet  is  to 
be  restricted  to  articles  of  a  readily  digestible  character.  If  diarrhoea 
persist,  it  is  to  be  treated  by  bismuth  and  small  doses  of  opium,  either 
alone  or  combined  with  the  mineral  acids;  if  there  be  a  tendency  to  con- 
stipation, simple  enemata  may  be  employed  for  its  relief.  Laxative 
medicines,  with  the  exception  of  castor-oil  in  small  doses,  are  inadmissi- 
ble. Milk-punch,  egg-nogg,  and  wine,  are  often  of  service  during  conva- 
lescence; but,  in  the  case  of  ^''oung  persons,  or  of  those  not  in  the  habit  of 
using  alcoholic  beverages  previous  to  their  sickness,  it  is  important  to 
■wholly  dispense  with  alcohol  as  early  as  possible.  Quinine,  iron,  and  cod- 
oil,  are  to  be  employed  if  the  convalescence  be  tardy  and  anaemia  persist. 
A  brief  sojourn  at  the  sea-shore  is  not  less  agreeable  than  useful;  the 
patient  gladly  escapes  from  the  apartment  which  has  been  the  scene  of 
his  tedious  illness,  and  finds  change  of  air  and  of  scene  invigorating  alike 
to  body  and  mind. 


y. 

TYPHUS  FEYEE. 

Definition. — A  specific  febrile  disease  of  from  ten  to  twenty-one — 
usually  fourteen — days'  duration,  highly  contagious,  arising  under 
circumstances  of  general  destitution  and  overcrowding,  and  pre- 
vailing in  more  or  less  extensive  epidemics.  It  is  characterized  by 
sudden  invasion;  great  and  early  prostration;  a  dull,  flushed  face; 
injected  conjunctivae;  wakefulness,  with  mental  torpor  and  confu- 
■  sion,  passing  at  the  end  of  the  first  week  into  delirium,  which  may 
be  active  and  noisy,  but  is  commonly  low  and  wandering;  stupor 
tending  to  coma;  tremors  and  involuntary  evacuations;  a  furred 
tongue,  soon  becoming  dry  and  brown;  in  most  instances,  constipa- 
tion; a  copious  rash  appearing  between  the  middle  and  the  end  of 
the  first  week,  disappearing  upon  pressure  at  first,  but  speedily  be- 
coming persistent,  and  often  associated  with  petechias.  After 
death  no  specific  lesion  ;  the  blood  is  broken  down,  the  heart  and 
voluntary  muscles  are  degenerated  and  softened,  the  internal  organs 
hyperaemic. 

Synonyms. — True  Typhus: 

Febris  pestilens;  Parish  Infection;  Infectious  Fever;  Pestilential 
Fever;  Der  ansteckende  Typhus;  Typhus  contagieux;  Tifo  conta- 
gioso;  Contagious  Fever;  Contagious  Typhus. 

Febris  epidemica;   Epidemic  Fever. 

Morbus  pulicaris;  Febris  purpurea  epidemia;  Febris  stigmata;  Febris 
petechialis;  Typhus  exanthematicus;  La  pourpre;  Fleckfieber;  Das 
Fleckenfieber;  Das  exanthematische  Nervenfieber;  Febbre  petecchi- 
ale;  Spotted  Fever;  Petechial  Fever;  Petechial  Typhus;  Typho-rube- 
oloid. 

Typhus  comatosus;  Brain  Fever. 

Febris  asthenica;  Fievre  ataxique;  Fi^vre  adynamique;  Adynamic 
Fever. 

Febris  putrida  et  maligna;  Synochus  putris;  Febris  maligna  pesti- 
lens; Febris  continua  putrida;  Fievre  putride  et  maligne;  Faul- 
16 


242  THE  CONTINUED  FEVERS. 

fieber;  Febbre  putrida;  Putrid  Malignant  Fever;  Putrid  Continual 
Fever. 

Pestis  bellica;  Typhus  bellicus;  Morbus  castrensis;  Febris  militaris; 
Typhus  castrensis;  Typhus  des  camps  et  des  armees;  Die  Kreigspest; 
Camp  Fever. 

Typhus  carcerum;  Febris  carceraria;  Maladie  des  prisons;  Jayle 
Fever;  Jail  Distemper. 

Fievre  des  hopitaux;  Malignant  Hospital  Fever. 

Febris  nautica;  Ship  Fever;  Infectious  Ship  Fever;  Ochlotic 
Fever. 

Catarrhal  Typhus;  Irish  Ague. 

The  foregoing  are  some  of  the  many  names  by  Tvhich  the  fever  under 
consideration  has  been  knov?n  and  described.  For  a  more  complete  list 
the  reader  is  referred  to  the  pages  of  Murchison.^  They  are  variously 
derived  from  the  contagious  character  of  the  fever,  its  prevalence  in  epi- 
demics, the  eruptions,  the  presence  of  cerebral  symptoms,  the  adynamia 
which  attends  it,  its  suj^posed  putrid  character,  and  its  malignancy;  or 
from  its  prevalence  in  armies,  in  camps,  in  hospitals,  in  prisons,  in  ships. 
Ochlotic  [6x^0^,  a  crowd)  is  an  adjective  of  modern  application,  derived 
from  the  supposed  mode  of  origin  of  the  fever  in  overcrowding. 

Typhus  (riKpo^,  smoke),  used  by  Hippocrates  to  define  a  confused 
state  of  the  mind,  with  a  tendency  to  stupor,  expresses  a  prominent  con- 
dition of  the  disease.  It  was  first  used  to  designate  certain  forms  of  con- 
tinued fever  by  Sauvages  in  1760.  Within  the  last  forty  years  it  has 
been  employed  by  English  writers  in  a  more  restricted  sense,  to  desig- 
nate the  particular  specific  fever  which  is  the  subject  of  the  present  arti- 
cle. Among  continental  writers  it  is  still  adapted  to  a  vaguely  defined 
group  of  the  continued  fevers. 

Historical  Sketch. 

According  to  Hirsch,'  it  must  remain  uncertain  whether  the  pestilence 
prevailing  in  Athens  at  the  time  of  the  Peloponnesian  war,  and  described 
by  Thucydides,  was  typhus  fever  or  not.  Equally  uncertain  is  the  nature 
of  the  numerous  epidemics  of  contagious  fever  which  occurred  in  differ- 
ent parts  of  Europe  during  the  first  fifteen  centuries  of  the  Christian  era, 
many  of  which  have  been  supposed  by  some  authors  to  have  been  typhus 
fever.  The  descriptions  of  the  historians  and  of  the  physicians  who  chroni- 
cled them,  are  alike  wanting  in  precision.  The  first  satisfactory  account 
of  typhus  dates  from  the  year  1501,  when,  according  to  Fracastorius,  it 

'  The  Continued  Fevers  of  Great  Britain. 
"Handbuch  der  hist.-geograph.  Pathologie. 


TYPHUS    FEVER.  243 

spread  from  Cyprus  into  Italy  as  a  new,  unheard-of,  and,  to  the  Italian 
physicians,  altogether  unknown  disease.  For  more  than  twenty  years  it 
prevailed  in  Italy.  If,  says  Hirsch,  we  may  place  confidence  in  the  phy- 
sicians and  historians  of  that  period  in  the  different  countries  of  Europe, 
we  are  compelled  to  believe  that,  in  the  beginning  of  the  sixteenth  cen- 
tury, typhus  fever  (Exanthematische  Typhus)  had  for  the  first  time  at- 
tained general  prevalence  over  the  continent.  By  the  middle  of  this  cen- 
tury it  had  become,  in  connection  with  the  plague,  the  predominant  form 
of  epidemic  disease.  At  that  time  the  movements  of  armies  and  military 
enterprises  contributed,  as  in  fact  they  have  at  all  periods,  greatly  to  its 
development  and  extension;  but  during  that  and  the  two  following  cen- 
turies it  appears  also  as  the  abiding  form  of  continued  fever  in  every 
country  of  Europe,  in  all  states  of  society,  and  as  playing,  under  many 
different  names,  the  most  prominent  part  among  epidemic  diseases.  As 
Murchison  well  says:  "  A  complete  history  of  typhus  would  be  the  history 
of  Europe  for  the  last  three  and  a  half  centuries."  Consult  his  work  for 
a  very  full  and  satisfactory  account  of  the  epidemics  that  have  been  the 
subjects  of  general  and  medical  history,  and  for  an  exhaustive  bibliogra- 
phy of  the  whole  subject.  The  brief  outline  of  the  following  pages  is 
based  principally  upon  the  works  of  the  authors  already  named — Hirsch 
and  Murchison. 

In  the  years  1550-54,  a  petechial  fever  prevailed  in  Tuscany  and  de- 
stroyed upwards  of  100,000  persons.  In  1557,  typhus  was  widely  preva- 
lent in  France.  It  again  prevailed  in  that  country  some  years  later,  in 
connection  with  the  plague. 

In  15G6,  typhus  appeared  in  Hungary,  in  the  army  of  Maximilian  II., 
and  spread  over  all  Europe. 

In  1580,  an  epidemic  of  typhus  arose  in  Verona.  The  historian  of 
this  epidemic,  Petrus  a  Castro,  states  that  the  fever  was  called  "  La 
pourpre  "  by  the  French,  "  Tabardiglio  "  by  the  Spaniards,  "  Petecchie  " 
by  the  Italians,  and  "Fleckfieber"  by  the  Germans.  Bleeding,  both  gen- 
eral and  local,  was  recommended  at  the  beginning  of  the  disease,  but  in 
the  later  stages  it  was  regarded  as  dangerous.  This  epidemic  spread  over 
Italy. 

In  1591,  famine  prevailed  in  Italy,  and  at  the  same  time  a  contagious 
fever  fell  upon  the  people  far  and  wide.  The  symptoms  were  the  same 
as  those  described  as  attending  the  epidemic  beginning  in  Verona  eleven 
years  before. 

A  similar  fever  prevailed  in  Holland  in  the  latter  part  of  the  sixteenth 
century. 

During  the  thirty  years'  war  (1609-1638)  all  Europe  was  devastated 
by  famine  and  by  a  contagious  fever,  which,  from  the  descriptions  of  vari- 
ous observers,  was  beyond  doubt  typhus. 

The  plague  appeared  in  Leyden  and  elsewhere  in  Holland,  in  1635, 


244  THE  CONTINUED  FEVERS. 

and  again  in  1G69,  and  on  each  of  those  visits  it  was  preceded  and  followed 
by  a  contagious  "  spotted  fever." 

About  the  year  1700,  F.  Hoffman,  professor  of  medicine  at  Halle, 
published  a  very  accurate  description  of  typhus  which  he  had  seen  among 
the  German  troops  in  1G83.  He  described  the  disease  under  the  name  of 
'' JFbbris  Petechialis  yera."  He  advised  acid  medicines,  nourishing  food, 
and  regarded  nothing  better  than  wine.  Under  the  name  of  febris  pes- 
tilens,  applied  by  the  authors  who  preceded  him  to  typhus,  he  described  the 
plague. 

From  1757  to  1759,  typhus  prevailed  in  Vienna.  It  was,  for  the  most 
part,  prevalent  in  overcrowded  localities. 

About  the  same  time  (1757-58)  occurred  the  first  epidemic  of  typhus 
in  Berlin  of  which  any  authentic  record  exists.  Its  origin  was  traced  to 
overcrowding,  with  deficient  ventilation  and  scarcity  of  food. 

•  In  17G4,  a  dreadful  epidemic  of  typhus  and  dysentery  prevailed  at 
Naples.  There  was,  at  that  time,  great  scarcity  of  provisions,  and  the 
poorer  classes  suffered  from  starvation.  The  people  from  the  surround- 
ing country  flocked  into  the  city,  and  their  overcrowding  and  misery  were 
beyond  description.     The  disease  raged  principally  among  the  poor. 

An  epidemic  of  typhus  occurred  in  1797-1800,  at  Genoa,  at  that  time 
besieged  by  the  French.  It  broke  out  when  the  garrison  was  half-fam- 
ished. 

With  the  wars  which,  during  the  first  fifteen  years  of  this  century, 
swept  over  almost  every  part  of  Europe,  typhus  anew  became  generally 
epidemic  upon  the  Continent.  It  prevailed  in  the  contending  armies  and 
among  the  inhabitants  of  the  countries  that  were  the  seat  of  war,  and, 
arising  invariably  under  circumstances  of  want  and  wretchedness,  it  was 
especially  frequent  and  fatal  among  the  inhabitants  and  garrisons  of  be- 
sieged cities. 

In  1816-17,  true  typhus  was  epidemic  in  Italy. 

Since  the  peace  of  1815,  typhus  has  frequently  occurred,  in  limited  or 
extended  epidemics,  in  different  parts  of  Europe. 

The  Baltic  provinces  of  Russia  and  Poland  have  often  suffered  from  it; 
Northern  and  Middle  Germany  have  been  frequently  infected.  In  Silesia, 
wide-spread  epidemics  have  raged  on  several  occasions,  and  particularly 
in  1847-48,  1850-57,  1868-69 — the  last  being  likewise  typhus  years  in 
East  and  West  Prussia,  and  in  the  Prussia  of  Posen  (Lebert).  Sporadic 
cases  of  typhus  occur  in  the  large  cities  of  Germany  almost  every  year, 
and  sporadic  cases  or  isolated  epidemics  have  also  in  late  years  been  ob- 
served in  Sweden,  Denmark,  Holland,  and  Belgium. 

Northern  Italy,  of  old  and  in  recent  years,  has  been  a  typhus-centre. 
The  fever  spreads  thence  to  Middle  and  sometimes  even  to  Southern  Italy 
on  the  one  hand,  and  on  the  other  it  crosses  the  Alps,  following  the  lines 
of  travel  into  Switzerland. 


TYPHUS    FEVER.  245 

The  statement  that  typhus  does  not  occur  in  France  is  not  true. 
Murchison  has  collected  evidence  to  prove  that  it  prevailed  at  Beaulieu  in 
1827,  at  Toulon  on  many  occasions  between  1820  and  ISoG,  at  Rheims  in 
1839,  at  Strasburg  in  1854. 

In  the  winter  of  1854-55,  it  made  its  appearance  among  the  English 
and  French  troops  in  the  Crimea;  but  its  prevalence  was  slight  compared 
with  that  of  the  following  winter,  when  it  was  mainly  confined  to  the 
French  and  Russian  armies.  During  the  first  six  months  of  185G,  it  is 
estimated  that,  out  of  a  force  of  120,000  French,  12,000  were  attacked 
with  typhus,  of  whom  one-half  died  (Murchison). 

Turning  our  attention  to  the  British  Islands,  we  find  that  in  1522  the 
first  of  the  "  black  assizes,"  hereafter  to  be  described,  occurred  in  Cam- 
bridge.     Murchison  regards  this  outbreak  of  fever  as  typhus. 

In  1577,  a  second  "  black  assize  "  occurred  at  Oxford,  and  in  158G  a 
third  at  Exeter.  These  outbreaks  of  fever,  apparently  communicated  to 
the  public  by  prisoners  brought  from  foul  jails  into  open  court,  appear  to 
be  the  earliest  distinct  records  of  typhus  fever  in  England.  But  these 
islands,  and  in  particular  Ireland,  have  been  the  geographical  home  of 
typhus  fever.  For  more  than  two  centuries  and  a  half  this  disease  has 
been  endemic  in  Ireland. 

In  the  spring  of  1G43,  at  the  siege  of  Reading,  a  fever  broke  out  in 
the  army  of  the  Earl  of  Essex,  and  in  the  garrison,  which  was  commanded 
by  Charles  I,  The  soldiers  of  both  armies  were  greatly  overcrowded. 
The  fever  presented  the  symptoms  of  typhus.  It  was  very  contagious, 
and  was  communicated  to  Oxford,  and  thence  spread  to  the  neighboring 
country,  where  it  proved  very  fatal. 

In  1658,  a  similar  fever  spread  over  England. 

The  great  plague  of  London  (1G65)  was  preceded  and  followed  by  a 
malignant  continued  fever,  the  symptoms  of  which  point  to  typhus. 

Sydenham  describes  an  epidemic  of  fever  which  began  in  London  in 
1685,  and  extended  over  the  whole  of  Britain. 

In  the  autumn  of  1698,  after  a  great  failure  of  the  crops,  a  fatal 
spotted  fever  began  to  prevail  all  over  England.  From  a  period  probably 
extending  as  far  back  as  the  beginning  of  the  seventeenth  century,  typhus 
had  been  known  in  Ireland  as  the  "  Irish  Ague."  Gerald  Boate  (1652) 
mentioned,  among  other  diseases  there  prevailing,  "  a  certain  sort  of 
malignant  feavers,  vulgarly  in  Ireland  called  Irish  agues,  because  at  all 
times  they  are  so  common  in  Ireland,  as  well  among  the  inhabitants 
and  the  natives  as  among  those  who  are  newly  come  thither  from  other 
countries." 

About  the  beginning  of  the  last  century,  medical  men  in  Ireland  began 
to  pay  great  attention  to  epidemic  diseases,  of  which  chronological  his- 
tories, extending  over  a  long  series  of  years,  were  published  later  in  the 
century  by  Rogers,  O'Connell,  Short,  and  Rutty.     From  these  authors  we 


246  THE  CONTINUED  FEVERS. 

learn  that  in  the  winter  of  1708-9,  after  a  poor  harvest  the  preceding  year, 
and  during  extremely  cold  weather,  a  fever  then  prevailing  in  Cork 
reached  its  climax.  It  then  "  declined  sensibly  for  a  year  or  two,"  and 
disappeared.  In  1718,  a  fever,  "  in  all  respects  the  same  "  as  that  of  1708, 
became  epidemic  in  Ireland,  and  prevailed  until  1721,  when  "it  abated  of 
its  severity,  dwindling  insensibly  away,  till  at  length  it  was  rarely  to  be 
met  with."  From  the*  description  of  this  fever  there  can  be  no  doubt 
that  it  was  typhus. 

A  similar  fever  arose  in  York  and  elsewhere,  in  England,  in  1718,  and, 
reaching  its  maximum  the  following  midsummer,  declined  rapidly,  and 
ceased  about  the  close  of  the  year  1719. 

From  1721  till  1728,  there  was  "  scarcely  any "  fever  in  Ireland. 
In  the  latter  year,  however,  after  three  successive  bad  harvests,  it  reap- 
peared, and  continued  to  prevail  for  four  years,  reaching  its  greatest  vio- 
lence in  1731.  This  fever  "  did  not  bear  bleeding."  On  the  contrary,  a 
tonic  and  stimulant  treatment  was  necessary.  This  epidemic  was  general 
over  Ireland,  and  extended  also  into  various  parts  of  England. 

Petechial  fever  was  prevalent  in  Ireland  in  the  spring  of  1735,  and  in 
1736,  but  no  great  epidemic  arose,  after  1731,  till  1740.  The  preceding 
winter  was  intensely  cold,  both  in  Great  Britain  and  Ireland;  numbers  of 
cattle  and  poultry  were  frozen  to  death,  while  the  harvests,  and  in  par- 
ticular the  potatoes,  were  destroyed.  There  was  great  distress  among  the 
poorer  classes,  many  of  whom  died  of  starvation. 

In  August,  1740,  a  fever  which  may  be  recognized  as  typhus  swept 
over  the  whole  of  Ireland,  raging  with  greatest  violence  in  the  province 
of  Munster,  where  the  poor  were  worst  provided  for.  This  epidemic  con- 
tinued through  the  following  year  (1741),  abating  in  fury  toward  its  close. 
In  the  winter  of  1742,  after  an  abundant  harvest,  it  had  almost  ended. 
The  poor  were  first  attacked,  but  the  rich  did  not  escape.  O'Connell 
computed  the  loss  of  life  in  Ireland  in  1740-41,  by  famine  and  fever,  at 
80,000. 

Murchison  calls  attention  to  the  fact  that  there  are  evidences  of  the 
association  of  relapsing  fever  with  typhus  in  Rutty's  description  of  this 
outbreak. 

A  little  later,  in  1740,  a  very  fatal  epidemic  appeared  in  England  and 
Scotland.  It  spread  to  London  in  1741.  This  fever  "could  not  bear 
bleeding."     It  was  best  treated  with  bark  and  acids. 

In  1750,  and  again  in  1751,  Sir  John  Pringle  described  typhus  as  the 
"hospital  or  jayl  fever."  He  remarked  that  "the  hospitals  of  an  army, 
when  crowded  with  sick,  or  at  any  time  when  the  air  is  confined,  produce 
a  fever  of  a  malignant  kind  and  very  mortal.  I  have  observed  that  the 
same  sort  arise  in  foul  and  crowded  barracks;  and  in  transport-ships, 
Avhen  filled  beyond  a  due  number  and  detained  long  by  contrary  winds, 
or  when  the  men  were  kept  at  sea  under  close  hatches  in  stormy  weather." 


TYPHUS    FEVER.  247 

Of  treatment  he  said:  "  Many  have  recovered  after  bleeding,  but  fev?-  who 
have  lost  much  blood,"  Pie  recommended  bark  and  serpentaria,  and  con- 
sidered wine  of  great  use. 

The  writers  of  this  period  constantly  allude  to  fevers  arising  in  jails, 
hospitals,  camps,  and  ships,  and  attribute  them  either  to  the  concentrated 
emanations  from  living  human  bodies,  or  to  contagion.  On  shipboard, 
typhus  was  then  a  very  common  disease,  esjoecially  on  the  long  voyages 
to  this  country. 

In  1770-71,  typhus  again  broke  out,  after  a  long  interval,  in  Ireland, 
and  raged  with  great  violence  for  about  a  year. 

In  1797,  there  arose  in  that  ill-fated  land  another  great  epidemic  of 
fever,  which  did  not  terminate  till  1803.  It  was  a  period  of  great  calam- 
ity; Ireland  had  been  threatened  with  foreign  invasion,  and  was  torn 
with  internal  rebellion.  Political  feeling  ran  high,  and  the  upper  and 
lower  classes  were  arrayed  against  each  other,  A  great  part  of  the  ten- 
antry of  the  large  estates  were  deprived  of  work.  There  was  a  series  of 
poor  harvests;  in  the  summer  of  1797  heavy  rains  injured  the  crops.  The 
three  following  years  were  no  better.  This  condition  of  things  resulted 
in  a  lack  of  food  among  the  poor.  The  prices  of  the  necessaries  of  life 
rose  enormously.  It  was  the  poor  who  chiefly  suffered,  but  in  proportion 
to  the  number  of  persons  attacked  the  fever  was  most  fatal  in  the  middle 
and  upper  classes.  The  harvest  of  1801  was  abundant,  and  provisions  of 
all  kinds  were  supplied  at  moderate  prices;  the  epidemic  at  once  began 
to  decline,  and  by  the  end  of  the  following  year  had  almost  spent  its 
force. 

It  spread  to  England,  but  was  there  less  prevalent  than  in  Ireland. 
This  epidemic  was  mainly,  but  not  wholly  typhus  ;  in  Ireland  relapsing 
fever  was  also  observed.  It  was  largely  in  consequence  of  the  prevalence 
of  fever  at  this  time  that  separate  hospitals,  for  the  reception  and  treat- 
ment of  fever-patients,  were  first  established  throughout  the  kingdom. 

In  1817-19,  there  arose  a  very  wide-spread  epidemic  of  fever  in  Ire- 
land; it  extended  also  to  England  and  Scotland,  but  prevailed  in  both 
much  less  extensively.  It  is  probable  that  this  epidemic  was  chiefly  con- 
stituted of  relapsing  fever  cases,  although  a  considerable  proportion  of 
typhus  cases  were  observed. 

It  is  estimated  that  in  this  epidemic  800,000  of  the  6,000,000  inhabi- 
tants of  Ireland  fell  sick,  and  of  these  45,000  died,  partly  of  fever,  partly 
of  famine  and  dysentery. 

The  next  great  epidemic  appeared  in  1836.  It  began  in  Dublin  in 
May,  1826,  and  prevailed  till  March,  1827.  Meanwhile  it  spread  to  Scot- 
land, where  it  reached  its  acme  in  1828.  It  prevailed  to  a  limited  extent 
in  London.  This,  like  the  preceding  epidemic,  was  composed  of  relaps- 
ing and  typhus  fever  cases  together. 

For  a  period  of  eight  years  typhus  fever  was  endemic  rather  than  epi- 


248  THE  CONTINUED  FEVERS. 

demic.  In  1831-32,  "  there  was  a  considerable  increase  "  of  it  in  Glasgow 
and  Edinburgh.  But  it  was  not  until  183G  that  it  assumed  the  magnitude 
of  an  epidemic.  This  time,  as  so  often  before,  it  broke  out  in  Ireland, 
and  found  its  way  thence  into  Scotland  and  England.  The  fever  of  this 
outbreak  was  typhus.  Hence,  the  mortality  was  far  in  excess  of  that  of 
the  previous  epidemics,  which  were,  in  great  part,  made  up  of  relapsing 
cases. 

In  1842,  fever  again  became  epidemic.  This  differed  from  previous 
outbreaks  in  neither  originating  in  Ireland,  nor  in  implicating  it.  The 
disease  was  general  over  Scotland,  but  was  by  no  means  restricted  to  the 
large  cities.  It  invaded  England,  but  its  ravages  there  were  much  less 
extensive  than  among  the  Scotch.  It  was  chiefly  prevalent  among  the 
poorest  and  most  wretched  of  the  population,  who  were  at  the  time  of  its 
outbreak  in  a  condition  of,  even  for  them,  unusual  distress.  The  cases 
were  almost  exclusively  relapsing  fever;  typhus  was  rare.  The  mor- 
tality was  from  two  and  a  half  to  four  per  cent.  Bleeding  was  but  little 
resorted  to;  the  treatment  was  of  a  supporting  kind;  many  cases  were 
thought  to  demand  stimulants.  The  distinction  between  relapsing  and 
typhus  was  clearly  recognized  in  this  epidemic,  and  the  cases  were  sep- 
arately entered  in  the  registers  of  the  infirmaries  of  Glasgow  and  Edin- 
burgh. 

Toward  the  end  of  the  year  1846,  a  fever  epidemic  of  great  magnitude 
and  severity  arose  in  Ireland  after  an  extensive  failure  of  the  potato-crop, 
and  at  a  time  of  great  consequent  hunger  and  want  among  the  people. 
It  prevailed  two  years,  sweeping  also  over  Scotland  and  England.  In  the 
latter  countries  the  cases  were  mainly  typhus,  while  in  Ireland  the  pre- 
dominant form  was  relapsing  fever.  The  amount  of  suffering  caused  by 
this  outbreak  was  appalling.  In  Dublin  alone,  40,000  cases  of  fever  oc- 
curred, and  it  is  estimated  that,  in  the  whole  of  Ireland,  the  total  number 
exceeded  1,000,000.  In  England,  300,000  cases  occurred,  and  in  Liverpool 
there  were  10,000  deaths  from  typhus.  In  Edinburgh,  2,503  persons  died 
of  the  fever,  and  it  was  estimated  that  not  less  than  19,254,  or  one- 
ninth  of  the  population,  were  ill  of  it. 

The  death-rate  of  this  epidemic  was  everywhere  high,  but  was  always 
highest  when  the  proportion  of  cases  of  typhus  to  relapsing  fever  was 
greatest.  In  Ireland,  8  per  cent,  died;  in  Edinburgh,  13  per  cent.;  in 
Glasgow,  14.41  per  cen.t.;  but,  separating  the  cases  of  relapsing  fever 
from  those  of  typhus,  we  find  that  in  Edinburgh  the  mortality  of  relaps- 
ing fever  was  4  per  cent.,  of  typhus  24.7  per  cent.;  and  in  Glasgow,  that 
of  relapsing  fever  6.38  per  cent.,  of  typhus  21.2  per  cent. 

At  this  period  (1847-48)  a  great  epidemic  of  typhus  and  relapsing 
fever  prevailed  in  Upper  Silesia  and  elsewhere  in  Germany. 

In  Great  Britain,  and  especially  in  Ireland,  typhus  fever  has  its  chief 
geographical  home.     Pestilential   centres  of  typhus   seem  to  exist  upon 


TYPHUS    FEVEK.  249 

the  Continent — for  example,  in  Northern  Italy,  the  Baltic  provinces,  and 
in  Silesia;  but  nowhere  in  modern  times  have  typhus  epidemics  occurred 
so  frequently  as,  or  excelled  in  magnitude,  those  of  the  British  Isles. 
Nowhere  in  the  intervals  between  epidemics  have  sporadic  cases  and  iso- 
lated outbreaks  been  so  constantly  observed  as  there.  In  these  lands, 
and  particularly  in  Ireland,  typhus  fever  is  peculiarly  endemic. 

No  authentic  account  exists,  according  to  Murchison,  of  typhus,  as  it 
is  known  in  European  countries,  in  Africa  or  the  tropical  parts  of  Amer- 
ica; nor  has  it  been  observed  in  Australia  or  New  Zealand,  except,  on  rare 
occasions,  among  the  passengers  landed  from  emigrant-ships.  The  same 
author  concludes,  after  a  review  of  the  somewhat  conflicting  statements 
of  writers  upon  the  diseases  of  India,  with  reference  to  this  subject,  that 
typhus  fever  must  henceforth  be  regarded  as  one  of  the  diseases  of  that 
country.  Hirsch  informs  us  that  together  with  the  plague,  it  is  endemic 
in  Simla.  The  natives  of  tropical  countries  possess  no  immunity  from 
typhus  on  visiting  localities  in  which  it  is  prevalent. 

Turning  our  attention  to  the  Western  hemisphere,  we  find  that  typhus 
fever  has  prevailed  in  the  United  States  and  British  North  America,  at 
various  times  in  restricted  epidemics.  There  is  reason  to  believe  that 
most  of  the  epidemics  that  prevailed  extensively  in  the  United  States 
during  the  early  part  of  the  present  century,  and  were  described  by  med- 
ical writers  of  the  period  under  such  names  as  "  spotted  fever,''''  '■'■  2')etechial 
typhus^''  and  '■'■typhus  syncopalis,''''  consisted  of  cerebral  spinal  fever.  In 
more  recent  times,  typhus  fever  has  not  infrequently  made  its  appearance 
in  the  cities  of  the  seaboard,  as  a  direct  importation  from  Ireland  and 
other  transatlantic  countries  in  which  it  has  prevailed.  Hence  the  pop- 
ular terms,  "Trw/i/eyer,"  '■'■  emigrant  fever^"*  ^'^  ship  fever.''''  Its  importa- 
tion has  without  doubt  been  more  frequent  in  recent  times,  in  consequence 
of  the  facility  and  rapidity  of  ocean  travel  and  the  enormous  immigration 
hitherward.  The  instances  of  its  supposed  autochthonous  origin  in  the 
United  States  are  readily  explicable  upon  the  theory  of  a  prolonged 
latent  existence  of  the  germs,  terminating  in  their  becoming  the  exciting 
cause  of  the  disease  under  favorable  circumstances;  that  is,  upon  the 
presence  and  coacurrent  action  of  the  predisjDOsing  causes.  Thus,  Hirsch 
states  that  he  has  been  able  to  find  but  seven  instances  of  the  sponta- 
neous origin  of  typhus  in  the  United  States  between  the  years  1817-56. 

The  first  of  these  broke  out  in  the  poor-house  in  Boston,  in  1816,  and 
extended  to  the  inhabitants  of  the  city.  The  second  occurred  in  Phila- 
delphia in  1820,  and  was  exclusively  confined  to  the  poor-house.  The 
third,  fourth,  and  fifth  occurred  in  1818,  1825,  and  1837,  in  the  prison  at 
Bellevue,  in  New  York,  and  prevailed  at  the  same  time  in  the  crowded  and 
destitute  portions  of  the  city.  The  sixth  of  these  outbreaks  was  observed 
in  Westchester  County,  among  railroad  laborers.  The  last  occurred  in 
the  year  1836,  among  the  most  wretched,  filthy,  and  impoverished  portion. 


250  THE    CONTINUED    FEVERS. 

of  the  population  of  Philadelphia,  and  extended  over  a  great  portion  of 
the  city.  This  outbreak  was  described  by  Gerhard  and  Pennock,  in  a 
paper  that  remains  to  this  day  the  most  important  contribution  to  medi- 
cal literature  upon  the  subject  of  typhus  in  the  United  States.'  It  is  only 
necessary  to  point  to  the  fact  that  all  these  outbreaks  occurred  in  or  near 
seaport  cities,  in  direct  communication  with  those  parts  of  the  world  in 
which  typhus  fever  makes  its  home,  and  that  each  of  them  arose  in  a  local- 
ity in  which  the  predisposing  causes  of  typhus  fever  probably  existed  to 
a  high  degree,  to  show  how  unstable  is  the  basis  upon  which  rests  the  belief 
that  the  disease  was,  in  these  instances,  of  spontaneous  origin.  The  ina- 
bility to  trace  the  contagion  in  any  outbreak  is  not  a  sufficient  warrant  for 
the  supposition  that  it  has  spontaneously  arisen. 

Typhus  has  repeatedly  appeared,  in  consequence  of  direct  and  easily 
traceable  importation,  in  New  York,  Philadelphia,  Boston,  and  Baltimore. 

There  are  no  records  of  its  occurrence  in  the  Gulf  States  or  upon  the 
Pacific  slope;  and  although  Drake,  in  his  "  Treatise  on  the  Diseases  of  the 
MississijDpi  Valley,"  treats  at  great  length  of  the  typhous  group  of  fevers, 
it  is  clear  from  his  descriptions  that  he  refers  principally  to  outbreaks  of 
enteric  and  cerebro-spinal  fever,  and  not  to  typhus  fever  as  we  know  it. 
In  fact,  typhus  is  not  a  disease  of  North  America.  It  occurs  here  only  in 
consequence  of  importation,  and  prevails  only  in  restricted  epidemics. 
Among  the  more  recent  outbreaks  are  to  be  mentioned  that  of  1850-52, 
in  Buffalo,  described  by  Flint;  that  of  18G1-65,  in  New  York,  of  which 
we  have  an  account  in  the  writings  of  Loomis;  and  that  of  1SG4,  in  Phila- 
delphia, which  forms  the  basis  of  the  excellent  paper  by  Da  Costa. 

Notwithstanding  the  existence  of  typhus  in  several  of  the  seaport 
cities  of  the  North  during  the  years  of  the  American  war,  it  is  a  remark- 
able fact  that  there  was  perhaps  entire  immunity  from  this  disease  in  the 
armies  both  of  the  United  States  and  the  Confederates.  Dr.  Clymer  ^ 
states  that,  as  a  result  of  large  personal  observation  and  diligent  inquiry 
among  the  medical  officers  of  the  United  States  army,  he  is  satisfied 
that,  as  an  epidemic,  however  limited,  typhus  never  prevailed,  even  at  the 
depots  for  returned  prisoners  of  war.  He  thinks  that  there  is  every  rea- 
son to  believe  that  the  cases,  1,723  in  number,  with  57^deaths,  reported 
to  the  ofiiee  of  the  Surgeon-General  of  the  United  States,  were  not  in- 
stances of  true  typhus. 

Students  of  medicine  in  American  cities  rarely  have  the  opportunity 
of  familiarizing  themselves  with  the  clinical  aspects  of  typhus.     Never- 


'  On  the  Typhus  Fever  which  occurred  at  Philadelphia  in  the  Spring  and  Summer 
of  1836  ;  illustrated  by  Clinical  Observations  in  the  Philadelphia  Hospital,  etc.,  etc., 
by  W.  W.  Gerhard,  M.D.:  Amer.  Jour.  Med.  Sc,  vol.  xix.,  p.  289  et  seq.,  and  vol.  xx., 
p.  289  et  seq.     Philadelphia,  1837. 

^  Aitkin's  Practice.  Vol.  i.  Article  Typhus.  Third  American  edition.  Philadel- 
phia, 1873. 


TYPHUS    FEVER.  251 

theless,  occasional  examples  of  this  disease  find  their  way  into  the  hospi- 
tals of  the  seaboard  towns.  Thus,  typhus  showed  itself  in  Philadelphia  iu 
the  spring  of  1880,  and  several  cases  were  at  that  time  treated  in  the 
wards  of  the  Philadelphia  Hospital.  During  the  summer  the  disease  dis- 
appeared, but  again  made  its  appearance  in  the  autumn,  and  is  still  pre- 
valent.    The  number  of  cases,  fortunately,  is  extremely  limited. 

Typhus  has  been  observed  under  similar  circumstances  of  direct  im- 
portation in  British  North  America,  where,  however,  the  epidemics  have, 
in  most  instances,  assumed  more  extensive  proportions  than  with  us. 

Etiology. 
i.  pkedisposing  causes. 

Climate  has  undoubtedly  an  influence  upon  the  development  and 
spread  of  typhus.  As  indicated  in  the  foregoing  historical  sketch,  its 
home  is  Europe  and  the  British  Isles.  If  it  be  endemic  in  India,  it  is  so  to 
a  very  limited  extent.  In  other  tropical  and  subtropical  countries  the 
typhus  of  Ireland  is  certainly  almost  unknown.  It  is  essentially  a  dis- 
ease of  cold  and  temperate  climates. 

The  season  of  the  year  appears  to  exert  very  little  influence  upon  ty- 
phus. Epidemics  arise  and  pursue  their  course  irrespective  of  the  season. 
It  has  sometimes  been  observed  that  the  number  of  cases  has  diminished 
during  the  summer,  and  again  increased  in  the  last  month  or  two  of  the 
year.  The  diminution  does  not  begin  at  once  upon  the  advent  of  warm 
weather,  nor  does  the  increase  follow  immediately  upon  cold.  A  contin- 
uance of  these  conditions  is  necessary  to  produce  their  respective  influence 
upon  epidemics.  From  this  it  would  appear  that  the  influence  is  due  to 
the  different  mode  of  life  incident  to  the  seasons,  and  that  the  increase  of 
typhus  in  the  winter  and  spring  months  is  due,  not  to  the  weather,  but  to 
the  protracted  overcrowding  and  deficient  ventilation  of  the  dwellings  of 
the  poor,  and  perhaps  also  to  a  greater  scarcity  of  food,  particularly  in 
times  of  scarcity,  in  the  winter. 

Meteorological  conditions  exert  little  or  no  influence  upon  typhus;  they 
are  by  no  means  constant  for  different  epidemics.  Hirsch  regards  a  low 
and  damp  situation  as  powerfully  predisposing  to  the  endemic  and  epi- 
demic prevalence  of  typhus,  but  insists  that  it  is  by  no  means  a  neces- 
sary or  important  factor  in  the  production  of  the  disease.  As  the  result 
of  importation,  typhus  may  occur  at  a  considerable  height  above  the  sea- 
level.  In  the  spring  of  1839,  Lebert  observed  a  considerable  number  of  cases 
on  the  plain  and  in  the  valley  of  the  Salvan,  in  the  lower  Valais,  at  a 
height  of  4,000  feet  above  the  sea.  The  disease  in  this  case  was  brought 
from  Piedmont,  over  the  St.  Bernard  pass,  and  at  least  one-third  of  the 
monks  at  the  Hospice  contracted  it. 


252  THE  CONTINUED  FEVERS. 

Age  affords  no  exemption  from  the  attack  of  typhus.  It  would  ap- 
pear, from  death  registers  and  hospital  reports,  that  it  is  for  the  most  part 
a  disease  of  adult  life.  The  mean  age  of  3,456  cases  admitted  to  the 
London  Fever  Hospital  during  ten  years  (1848-57)  was,  according  to 
Murchison,  29.33  years;  and  of  18,138  cases  admitted  in  twenty-three 
years  (1848-70),  more  than  one-half  (9,248)  occurred  between  the  ages 
of  ten  and  thirty;  the  youngest  was  ope  month,  the  oldest  eighty-four 
years. 

The  evidence  furnished  by  data  of  this  kind  is  untrustworthy  as  indica- 
ting the  relative  liability  to  typhus  at  different  periods  of  life.  Children, 
for  obvious  reasons,  contribute  a  relatively  smaller  number  of  cases  to  hos- 
pital statistics  than  adults,  and,  for  the  reason  that  the  disease  is  much 
less  fatal  in  the  early  years  of  life,  they  contribute  an  actually  smaller 
number  to  mortality  statistics.  In  view  of  the  fact  that  many  adults  are 
protected  by  previous  attack,  it  is  probable  that  all  periods  of  life  are  alike 
susceptible  to  the  exciting  cause  of  typhus. 

jSex  in  itself  has  no  influence.  Up  to  thirty  years  of  age  rather  more 
males  than  females  contract  typhus;  above  the  age  of  thirty  years  the  re- 
verse is  true.  Taking  all  ages  together,  the  number  of  cases  is  about  the 
same  for  each  sex. 

Occupation,  except  as  it  involves  actual  exposure  to  the  contagion,  as 
the  case  of  hospital  attendants,  physicians,  clergymen,  etc.,  does  not 
predispose  to  t^^phus.  Patients  admitted  to  hospital  suffering  with  this 
fever  are  almost  always  in  destitute  circumstances,  and,  if  possessed  of 
a  trade,  have  usually  been  out  of  employment  so  long  that  it  could  not 
be  regarded  as  exerting  any  influence  whatever.  Numerous  observers 
have  thought  that  butchers  are  less  liable  to  typhus  than  those  engaged 
in  other  pursuits.  The  fact  may  be  accounted  for  by  their  alvvays  having 
a  good  supply  of  food.  The  laboring  classes  are  more  liable  than  the 
well-to-do  middle  classes,  probably  for  analogous  reasons. 

Habitual  alcoholic  excesses  predispose  to  typhus.  Murchison  states 
that  a  single  act  of  intoxication  may  render  the  subject  liable  to  it;  that 
he  has  "  known  several  instances  of  persons  exposed  for  months  to  the 
poison  in  its  most  concentrated  form,  who  were  not  attacked  until  imme- 
diately after  a  debauch." 

Previous  illness  is  thought  to  predispose  to  typhus.  In  general  hos- 
pitals, the  convalescents  from  other  diseases  not  infrequently  contract 
typhus.  Many  persons,  who  during  epidemics  have  long  escaped  the 
fever,  are  seized  with  it  after  a  slight  attack  of  sickness.  In  the  Crimean 
war,  scurvy  was  found  to  be  a  powerful  predisposing  cause.  Phthisis, 
quiescent  before,  has  frequently  been  observed  to  run  a  rapid  course  after 
an  attack  of  typhus. 

Fatigue,  both  bodily  and  mental,  want  of  sleep,  anxiety  and  other  de- 
pressing emotions,  particularly  a  dread  of  the  disease,  increase  the  liability 


TYPHUS    FEVEK.  253 

to  the  attack.  These  influences  have,  in  very  many  instances,  appeared 
to  determine  the  seizure  among  medical  students,  clinical  clerks,  nurses, 
and  other  attendants  upon  the  sick.  Among  the  predisposing  influences, 
is  to  be  mentioned  personal  idiosyncrasy.  Different  individuals  possess 
for  typhus,  as  for  other  contagious  diseases,  a  varying  degree  of  personal 
susceptibility  independent  of  other  circumstances  of  predisposition. 

Tlie  mode  of  life  of  the  individual  exerts  a  powerful  predisposing  in- 
fluence. Typhus  is  a  disease  of  the  poor  and  underfed  of  large  cities. 
With  the  exception  of  persons  of  the  better  classes  who  contract  the  dis- 
ease by  direct  exposure  to  the  contagion,  it  is,  under  the  ordinary  circum- 
stances of  its  endemic  or  mildly  epidemic  prevalence,  confined  to  the 
indigent  classes  and  those  just  above  the  indigent  classes  of  the  com- 
munity. It  is  only  under  unusual  circumstances,  or  in  fierce  epidemics, 
that  it  attacks  those  who  are  well-to-do.  It  was  found,  upon  inquiring 
into  the  antecedent  history  of  18,268  typhus  patients  admitted  into  the 
London  Fever  Hospital  during  twenty-three  years,  that  they  belonged 
almost  invariably  to  the  lowest  classes  of  the  population,  95.76  per  cent, 
being  the  inmates  of  workhouses  or  dependent  upon  parochial  relief, 
whereas  comparatively  few  of  the  better  class  of  patients,  who  were  able 
to  pay  for  admission,  were  affected  with  typhus.  A  large  proportion  of 
the  typhus  patients  had  been  on  the  verge  of  starvation  for  several  weeks 
or  months  prior  to  admission  (Murchison). 

The  great  epidemics  of  typhus,  not  only  in  Ireland  and  Great  Britain, 
but  also  upon  the  Continent,  have  invariably  occurred  in  times  of  scarcity. 
They  have  followed  failure  of  the  crops,  and  prevailed  generally  over  lands 
visited  by  famine;  or  they  have  arisen  in  consequence  of  the  hardships  of 
war,  sieges,  commercial  distress,  or  strikes  in  the  manufacturing  districts, 
and  have  remained  to  a  greater  or  less  extent  circumscribed. 

Overcroiodmg ,  beyond  all  question,  plays  the  most  important  part 
among  the  predisposing  causes  of  typhus.  The  conditions  which  consti-. 
tute  overcrowding  are,  in  the  words  of  Dr.  George  Buchanan,'  "  scarcely 
to  be  separated  from  each  other,  but  may  be  enumerated  as  overcrowd- 
ing of  dwelling-houses  upon  a  too  limited  area,  overcrowding  of  rooms  by 
too  many  occupants,  bad  ventilation  of  streets  and  houses,  domestic 
and  personal  dirtiness."  To  the  combined  influence  of  these  conditions 
is  due  the  proneness  of  the  laboring  population  of  great  cities  to  typhus. 
Murchison  found  that  in  London  the  cases  admitted  to  the  Fever  Hospi- 
tal were  for  the  most  part  brought  from  the  central  and  most  crowded 
localities,  and  that  on  approaching  the  suburban  districts  their  proportion 
gradually  diminishes.  In  Liverpool,  which  has  habitually  more  cases  of 
typhus  than  any  other  town  of  England,  and  in  which  the  most  serious 
epidemics  occur,  the  huddling  together  of  houses  with  insufficient  space 

'  Reynolds'  System.     Article  Typhus,  vol.  i. 


254  THE  CONTIXUED  FEVERS. 

around  them  is  carried  on  to  a  greater  degree  than  in  any  other  town  in 
the  kingdom.  A  large  number  of  the  houses  are  built  back  to  back  in 
unventilated  courts,  and  the  population  is  so  dense  that  in  some  districts 
each  person  only  gets  eight  square  yards  of  superficial  space.  In  these 
parts  it  is  that  fever  especially  flourishes,  and,  in  epidemic  periods,  passes 
by  none  but  those  who  are  protected  by  previous  attack  (Buchanan).  In 
Edinburgh,  where  the  overcrowded  dwellings  of  the  poor  and  the  houses 
of  the  better  classes  are  perhaps  more  widely  separated  than  in  any  other 
city,  typhus,  even  in  the  midst  of  the  greatest  epidemics,  is  almost  re- 
stricted to  the  most  crowded  and  wretched  parts  of  the  Old  City  (Mur- 
chison).  Glasgow  is  another  of  the  cities  in  which  the  houses  occupied 
by  the  poor  are  densely  crowded  together.  Its  inhabitants  have  likewise 
been  great  and  constant  sufferers  from  typhus,  which  has  been  found  to 
prevail  most  fiercely  in  the  more  crowded  parts,  and  to  leave  the  more 
open  districts,  inhabited  by  the  opulent,  almost  or  quite  unscathed. 

The  crowding  together  of  many  persons  in  small  rooms  with  deficient 
ventilation  is  not  a  less  potent  predisposing  cause.  Hence,  in  former  times, 
the  ill-repute  of  the  lodging-houses  frequented  by  the  poor  in  the  large 
towns  of  Great  Britain  and  Ireland.  Of  these  there  are  great  numbers, 
and  previous  to  the  enactment  of  laws  regulating  their  management,  in 
1857,  they  were  pestilential  centres,  perennial  hot-beds  of  typhus,  where 
the  fever,  like  a  spark  under  the  ashes,  forever  glimmered,  ready  to  burst 
forth  into  the  flame  that  so  often  swept  the  land  from  end  to  end. 

Typhus  has  very  frequently  arisen,  both  in  early  and  recent  times, 
under  circumstances  of  overcrowding,  in  hospitals,  prisons,  ships,  and 
armies.  Sir  John  Pringle  in  1752  gave  it  the  name  of  "Hospital  Fever." 
The  "Gaol  Fever"  and  "  Jayl  Distemper"  of  former  times  was  typhus. 
Common  in  the  overcrowded,  foul,  and  ill-ventilated  prisons,  it  spread 
thence  to  the  communities  around  them.  Such  is  the  origin  of  the  "  black 
assizes  "  already  alluded  to,  three  of  which  occurred  in  the  sixteenth  and 
three  in  the  eighteenth  century.  They  are  of  interest  as  showing  in  a 
remarkable  manner  the  condition  of  the  prisoners  and  the  intense  activity 
of  the  typhus  contagion  in  densely  crowded  and  unventilated  rooms. 
They  certainly  do  not  prove  the  independent  origin  of  the  specific  excit- 
ing cause.  The  accounts  are  transcribed  from  the  pages  of  Murchison, 
by  whom  they  were  collected  from  the  writings  of  "Ward,  Bancroft,  Hux- 
ham,  and  others. 

"  The  first  occurred  at  Cambridge,  during  the  Last  Quarter  Sessions 
in  1522,  the  thirteenth  year  of  the  reign  of  Henry  YIII,  The  justices, 
gentlemen,  bailiffs,  and  most  of  the  persons  present  in  court,  were  seized 
with  a  fever,  which  proved  mortal  to  a  considerable  number.  No  account 
is  preserved  of  the  symptoms  of  this  fever;  but  the  circumstances  were 
similar  to  those  of  subsequent  black  assizes,  in  which  the  disease  was  un- 
doubtedly typhus. 


TYPHUS    FEVER.  "200 

"The  year  1577,  or  twentieth  of  the  reign  of  Queen  Elizabeth,  was 
notorious  for  the  Oxford  "  black  assize."  This  assize  was  held  at  Oxford 
Castle,  on  July  4th  and  two  following  days,  for  the  trial  of  Rowland 
.Tencks,  a  bookbinder  and  a  Roman  Catholic,  for  treason  and  profanity 
of  the  Protestant  religion.  Jencks  was  not  the  only  prisoner  brought 
before  the  court,  but  the  accounts  state  that,  after  judgment  was  pro- 
nounced against  him,  '  an  infectious  damp  or  breath  arose  among  those 
present.  Many  seem  to  have  been  taken  ill  on  the  spot.  Above  six 
hundred  sickened  in  one  night,  and  the  day  after,  the  infectious  air  being 
carried  into  the  next  village,  sickened  there  a  hundred  more.'  On  the 
15th,  IGth  and  17th  of  July,  three  hundred  more  fell  sick;  and  between 
the  Gth  of  July  and  the  12th  of  August  five  hundred  and  ten  persons 
perished.  The  following  are  mentioned  as  the  symptoms:  loss  of  appe- 
tite, great  headache,  sleeplessness,  loss  of  memory,  deafness,  and  delirium 
so  that  the  patients  would  get  up  and  walk  about  like  madmen.  The 
general  impression  at  the  time  was  that  the  'infection  arose  from  the 
nasty  and  pestilential  smell  of  the  prisoners  when  they  came  out  of  the 
jail,  two  or  three  of  whom  had  died  a  few  days  before  the  assize  began;' 
the  only  other  explanation  offered  being  that  it  resulted  from  the  *  dia- 
bolical machinations  of  the  papists,'  or,  according  to  the  Catholics,  that 
it  was  a  miraculous  judgment  on  the  cruelty  of  the  judge  for  sentencing 
the  bookbinder  to  lose  his  ears. 

"  In  1586,  another  '  black  assize  '  occurred  at  Exeter.  Some  time  be- 
fore, thirty-eight  Portuguese  seamen  had  been  cast  into  '  a  deep  pit  and 
stinking  dungeon  '  in  Exeter  Castle.  They  had  no  change  of  raiment,  and 
were  left  to  lie  upon  the  bare  ground.  A  contagious  fever  broke  out 
among  them,  which,  from  Hollingshed's  description,  was  evidently  typhus. 
Many  of  them  were  sick  during  their  trial,  and  by  them  the  disease  was 
communicated  to  those  present  in  the  court.  The  judge,  three  knights, 
and  many  others  died,  and  the  disease  spread  over  the  whole  county. 
In  this  instance  very  few  became  ill  until  fourteen  days  after  the  trial. 
The  fever  was  believed  to  have  proceeded  from  '  contagion  by  reason  of 
the  close  aire  and  filthie  stinke  of  the  gaole.' 

"  There  are  accounts  of  a  fourth  '  black  assize '  at  Taunton,  during 
Lent,  in  1730.  A  contagious  fever  was  communicated  by  the  prisoners, 
who  had  been  removed  from  Ilchester  jail,  to  the  judges  and  many  others 
in  the  court.  The  Lord  Chief  Baron,  the  Sergeant-at-law,  and  the  High 
Sheriffs  of  Somersetshire,  all  died  of  the  disease,  which  spread  widely  at 
Taunton,  and  proved  fatal  to  several  hundreds. 

"Twelve  years  later  there  was  a  fifth  'black  assize'  at  Launceston, 
an  account  of  which  is  contained  in  the  writings  of  Huxham.  'A  putrid, 
contagious  and  highly  pestilential  fever,  which  had  been  geiierated  i?i  the 
prisons,'  was  widely  disseminated  by  means  of  the  county  assize,  and 
occasioned  great  mortality.     Among  the  symptoms  were  great  prostration 


25G  THE    CONTINUED    FEVERS. 

and  oppression,  a  florid  rash  with  petechiae,  -watchfulness,  delirium,  tre- 
mors, subsultus,  black,  dry  tongue,  and  fetid  breath.  The  pulse  was  weak 
from  the  commencement,  even  in  the  robust,  and  '  bleeding  killed  the  pa- 
tient, and  not  the  disease.' 

"The  sixth  and  last  'black  assize  '  was  that  of  the  Old  Bailey,  in 
1750.  Nearly  a  hundred  prisoners  were  tried,  who  were  all,  during  the 
sitting  of  the  court,  either  placed  at  the  bar  or  confined  in  two  small 
rooms  which  opened  into  the  court.  The  court  was  crowded  to  excess, 
and  many  present  were  'sensibly  affected  with  a  very  noisome  smell.' 
Within  a  week  or  ten  days  many  of  those  present  were  seized  with  a 
'malignant  fever,'  among  the  symptoms  of  which  were  a  weak  pulse,  de- 
lirium, and  petechias.  Its  duration  was  a  fortnight.  That  this  was  the 
jail  distemper  or  typhus  appears  from  a  pamphlet  published  at  the  time 
by  Sir  John  Pringle.  Neither  the  prisoners  under  trial,  nor  any  in  the 
jail,  were  suffering  at  the  time  from  typhus." 

There  are  many  instances  where  typhus  has  attacked  individuals  and 
families  or  isolated  bodies  of  men,  as  in  jails  or  on  shipboard,  without 
traceable  contagion.  Dr.  Murchison  has  collected  a  number  of  such  ex- 
amples, which  he  adduces  in  support  of  the  theory  of  the  independent 
spontaneous  origin  of  typhus  by  the  intense  action  of  its  predisposing 
causes,  advocated  by  himself  and  others.  If  the  infecting  principle  or 
contagion  be  a  minute  organism  capable  of  indefinitely  reproducing  itself 
in  the  human  body  and  in  other  favorable  localities,  as  has  been  rendered 
almost  certain  by  the  discovery  of  the  parasitic  exciting  cause  of  the 
congener  of  typhus,  relapsing  fever,  it  is  more  in  accordance  with  modern 
views  to  suppose  a  continuous  latent  existence  of  the  germs,  which  are 
called  into  activity  by  overcrowding,  destitution,  and  other  predisposing 
causes,  than  to  accept  the  theory  of  its  independent  generation  de  novo. 
The  examples  in  question  are  capable  of  explanation  quite  as  satisfacto- 
rily by  the  former  as  by  the  latter  supposition. 

This  brings  us  to  the  consideration  of  the  exciting  cause. 

n.   THE  EXCITING  CAUSE. 

Typhus  fever  is  due  to  an  infecting  principle,  communicable  from  the 
sick  to  the  well  by  actual  contact,  by  means  of  the  atmosphere,  by  fomites, 
and  by  drinking-water.  The  nature  of  this  principle  is  unknown.  In 
the  words  of  Lebert,  "when  contagion  plays  a  part  so  important,  one  is 
forced  to  admit  a  specific  cause  for  a  disease  so  absolutely  defined  and 
so  well  characterized.  Such  can  only  be  an  organic  poison  or  an  organ- 
ized germ.  A  poison  may  kill,  but  cannot  infect,  still  less  spontaneously 
multiply  to  an  enormous  degree;  while  everything  in  the  history  of  this 
disease  admits  a  ready  explanation  through  organized  germs." 

Typhus  is  pre-eminently  contagious.    When  it  appears  in  a  community 


TYPHUS    FEVER.  257 

it  spreads  rapidly  among-  the  susceptible  persons.  The  rapidity  and 
extent  of  its  spread  is  proportionate  to  the  intensity  and  diffusion  of  the 
conditions  known  as  predisposing  causes,  but  persons  exposed  to  none  of 
the  predisposing  causes  contract  the  disease  when  in  close  attendance 
upon  those  ill  of  it.  The  prevalence  of  typhus  in  restricted  localities  is 
in  proportion  to  the  degree  of  intercourse  between  the  healthy  and  the 
sick.  When  it  breaks  out  in  a  house,  those  living  in  the  same  room 
with  the  person  first  attacked  are  usually  the  next  in  order  to  develop 
the  disease.  In  hospitals  the  nurses  and  resident  physicians  are  much 
more  commonly  attacked  than  the  attending  physicians  or  students. 
The  medical  assistants  in  the  British  fever  hospitals  rarely  escape  the 
disease.  During  the  year  1827,  in  the  Edinburgh  Infirmary,  ten  clinical 
clerks  and  twenty-five  nurses  or  servants,  caught  typhus;  all  of  them  had 
frequent  and  close  communication  with  the  fever-patients;  whereas  the 
clerks  and  nurses  residing  in  the  same  building,  who  had  no  intercourse 
with  fever-patients,  almost  uniformly  escaped.'  Instances  might  be  mul- 
tiplied indefinitely  in  support  of  this  statement.  During  twenty-three 
years  (1848-70)  288  cases  of  typhus  originated  in  the  London  Fever  Hos- 
pital. Of  these,  193  were  nurses  and  other  attendants  in  the  wards,  14 
were  medical  officers,  7  laundresses,  and  only  3  servants  not  engaged 
in  the  wards;  71  were  patients  admitted  for  other  diseases  (Murchison). 
In  1814,  typhus  was  brought  to  the  Salpetriere,  in  Paris,  by  some  soldiers; 
of  the  persons  attached  to  the  hospital  120  were  attacked  and  eight  phy- 
sicians died.  During  two  and  a  half  months  in  1856,  600  of  the  attend- 
ants in  the  French  military  hospitals  in  Constantinople  contracted  typhus, 
which  was  not  then  prevalent  in  the  city  itself. 

Typhus  is,  in  all  epidemics,  imported  into  localities  previously  free  from 
it,  by  infected  persons.  It  is  in  this  way  that  the  disease  has  made  its 
way  to  the  seaport  towns  of  this  country.  Hence  its  names:  Irish  fever, 
emigrant  fever,  and  so  on.  Very  often  in  general  hospitals  the  admis- 
sion of  a  single  case  of  typhus  is  followed  by  its  spread  among  the  attend- 
ants and  the  other  patients.  Tiie  prompt  removal  of  the  first  cases  from 
the  house  or  locality  in  which  the  disease  has  made  its  appearance  has 
often  arrested  its  spread,  while  the  neglect  of  this  measure  has  converted 
such  house  or  locality  into  a  focus  of  contagion. 

The  disease  may  be  and  constantly  is  communicated  from  the  sick  to 
the  well  by  actual  contact.  This,  however,  is  by  no  means  necessary. 
The  infecting  principle  is  in  all  probability  borne  in  the  expired  air  of 
the  patients  and  in  the  exhalations  from  their  cutaneous  surfaces.  It 
may  be  thus  carried  into  the  surrounding  atmosphere,  and  so  reach  the 
blood  of  those  quite  near  at  hand  by  the  channel  of  the  breath  or  by  the 

'  W.  P.  Alison,  M.  D. :  Observations  on  the  Epidemic  Fever  now  prevalent  among 
the  Lower  Orders  in  Edinburarh.     Edinburgh  Med.  and  Sur.  Jour.,  xxviii. ,  1837. 

17 


258  THE  CONTINUED  FEVERS. 

saliva  wliich  they  swallow.  But  tlie  distance  to  which  it  may  be  thus 
conveved  cannot  be  great.  If  the  room  occupied  by  the  patient  be 
spacious,  airy,  and  clean,  the  risk  of  contagion  is  very  slight.  Physicians 
who  visit  j)atients  in  such  apartments  with  due  precaution,  and  pass  at 
once  into  the  open  air,  incur  but  little  liability  to  contract  the  disease;  but 
those,  on  the  other  hand,  who  heedlessly  inhale  the  atmosphere  immedi- 
ately surrounding  the  patient,  or  incautiously  perform  auscultations,  or 
who  tarry  in  his  presence,  especially  if  the  apartment  be  small  and  im- 
perfectly aired,  incur  great  risk.  Typhus  is  never  communicated  by 
means  of  the  atmosphere  from  fever  hospitals  to  the  houses  in  their  im- 
mediate neighborhood.  Lebert  states  that  in  his  wards  at  Breslau,  during 
the  epidemic  of  1868-69,  when  the  greatest  attention  was  paid  to  ventila- 
tion both  in  winter  and  summer,  neither  typhus  nor  relapsing  fever  was 
propagated. 

The  breath  of  typhus-patients  conveys,  and  their  bodies  emit  when 
the  bed-clothes  are  turned  down,  a  peculiar,  strong,  somewhat  pungent 
odor,  which  has  been  regarded  by  many  observers  as  characteristic  of  this 
disease.  It  has  been  thought  that  those  in  whom  this  fever-odor  is 
strongest  are  most  likely  to  communicate  the  disease  to  others.  The 
fact  is  well  attested  that  man}'  persons,  Avho,  upon  coming  into  close 
proximity  with  patients,  have  felt  a  sickening  sense  of  the  intensity  of 
this  odor,  have  within  a  very  short  period  developed  the  disease.  Articles 
of  all  kinds  with  which  the  patient  comes  in  contact  may  become  carriers 
of  the  contagion.  It  is  probable  that  the  germs  of  typhus,  in  a  dried 
state,  or,  at  all  events,  in  a  condition  of  diminished  activity,  may  retain 
their  vitality  for  an  indefinite  period,  in  the  absence  of  conditions  favor- 
able to  their  development  or  multiplication — in  other  words,  in  the  absence 
of  the  predisposing  causes  of  the  disease.  Not  only  the  bedding  and 
clothing  of  the  patients,  but  also  the  apartment  in  which  they  have  lain, 
may  act  a.s  fomites.  Particular  houses,  in  this  way,  become  hot-beds  for 
the  production  of  the  disease;  ships  used  for  the  transportation  of  typhus- 
patients,  become  the  home  of  the  infection,  and  vehicles  used  to  convey 
patients  to  the  hospital  may  communicate  the  sickness  to  their  next  oc- 
cupants. Those  who  wash  the  undisinfected  clothing  of  typhus-patients 
are  peculiarly  liable  to  take  it.  Woollen  substances  are  more  apt  to  ab- 
sorb and  retain  the  contagion  than  other  textures,  and  garments  of  a 
dark  than  those  of  a  light  color. 

Not  only  may  the  disease  be  thus  conveyed  to  a  distance  by  articles 
of  the  most  varied  description  capable  of  carrying  the  contagion,  but  in- 
dividuals not  themselves  sick  of  the  fever  may  be  the  means  of  communi- 
cating the  disease  from  the  sick,  or  from  infected  localities,  to  the  healthy 
at  a  distance.  Thus,  in  January,  1867,  a  patient  in  a  surgical  ward  of  the 
Middlesex  Hospital  was  seized  with  typhus.  She  had  been  in  the  hospi- 
tal four  and  a  half  months,  and  in  bed  all  the  time.      There  were  no  other 


TYPHUS    FEVER.  259 

leases  of  typhus  in  the  same  ward  or  on  tlie  same  floor:  but  a  nurse  in 
close  attendance  upon  a  typhus-patient  down-stairs,  though  in  good  health 
herself,  had  been  in  the  habit  of  visiting  this  patient  daily  (Murchison). 
It  is,  however,  fortunate  that  the  contagion,  in  order  to  be  conveyed  by 
means  of  fomites,  must  be  concentrated,  and  that  habits  of  cleanliness  and 
caution,  and  free  ventilation,  reduce  this  danger  to  a  minimum.  Drs. 
Gregory,  Tweedie,  and  Murchison  have  separately  recorded  their  belief 
that,  in  an  attendance  upon  typhus-patients  extending  over  many  years, 
they  have  in  no  case  been  the  means  of  the  communication  of  the  fever. 

The  disease  may  be  contracted  by  susceptible  persons  through  contact 
with  the  bodies  of  persons  who  have  died  of  it.  There  are  no  facts  to 
prove  that  it  is  disseminated  from  the  dejections,  as  is  the  case  with  en- 
teric fever.  The  period  of  incubation  is  placed  by  Murchison  at  twelve 
days  or  less,  rarely  longer;  by  Lebert  at  from  five  to  seven  days.  There 
are  no  reliable  facts  in  support  of  the  statement  that  it  sometimes  exceeds 
three  weeks.  A  number  of  cases  have  been  recorded  in  which  the  symp- 
toms of  the  disease  appeared  immediately  upon  exposure.  In  these  in- 
stances the  possibility  of  previous  unsuspected  exposure  is  to  be  con- 
sidered. 

Lebert  holds  the  opinion  that  the  contagion  of  typhus  and  relapsing 
fever,  as  of  other  contagious  diseases,  must  in  many  instances  be  dissem- 
inated by  generally  acting  local  causes.  He  regards  the  ground — and 
drinking-water  as  together  playing  an  important  part.  This  opinion  is 
based  upon  the  simultaneous  or  nearly  simultaneous  infection  of  several 
persons  in  the  same  house  or  locality  at  the  beginning  of  an  epidemic,  a 
circumstance  which  the  communication  of  the  disease  from  the  sick  to 
the  well  cannot  explain.  Typhus  is  but  little  contagious  during  the  first 
week;  the  period  in  which  it  is  most  likely  to  be  communicated  is  from 
the  end  of  the  first  week  to  convalescence.  After  the  disappearance  of 
the  fever  and  the  return  of  appetite  and  digestion,  the  danger  of  conta- 
gion is  slight.  It  is,  however,  to  be  borne  in  mind  that  the  clothing  of 
the  patient,  and  articles  in  the  sick-room,  may,  even  at  this  period  and 
long  afterward,  unless  disinfected  and  exposed  to  the  air,  transmit  the 
specific  cause  of  the  disease. 

The  contagion  of  typhus  is  destroyed  by  prolonged  exposure  to  mod- 
erate dry  heat  (95.5°  C.  [204°  F.]). 

Immunity  from  a  second  attack  is  enjoyed  by  a  majority  of  the  per- 
sons who  have  suffered  from  typhus.  Nevertheless,  many  cases  of  well- 
marked  second  attacks  attended  by  the  eruption  are  recorded.  It  is 
probable  that  an  abortive  attack  is  less  apt  to  confer  immunity  than  the 
fully  declared  disease. 

The  lower  animals,  so  far  as  is  known,  do  not  suffer  from  any  disease 
identical  with  human  typhus,  nor  is  it  communicable  to  them  (Murchison). 
The  experiments  of  Mosler,  Obermeier,  and  Zuelzer,  upon  dogs,  rabbits, 


2G0  THE    CONTINUED    FEVERS. 

and  guinea-pigs,  have  yielded  contradictory  results.  Even  where  these 
animals  have  died,  after  the  intravenous  injection  of  the  blood  of  typhus- 
]):itieiits,  with  the  symptoms  of  an  acute  infection,  it  is  impossible  to 
alHrm  that  this  disease  has  been  typlius,  for  the  reason  that  typhus  pre- 
sents no  specific  lesion.  At  the  autopsy  of  ten  rabbits,  Zuelzer  found 
localized  pneumonic  patches  in  two;  in  the  eight  others,  congestion  of  the 
lungs,  the  kidneys,  and  the  liver.  But,  as  Jaccoud  '  has  pointed  out,  this 
does  not  warrant  the  conclusion  that  they  died  of  typhus. 

Clinical  History. 

The  evolution  of  tvphus,  clinically  considered,  is  continuous  rather  than 
by  a  succession  of  distinct  stages  or  periods.  From  the  onset  of  the  at- 
tack, which  is  usually  abrupt,  to  the  defervescence,  which  is,  in  by  far  the 
greatest  number  of  instances,  critical,  the  march  of  the  symptoms  is  pro- 
gressive; and  if  stages  can  be  artificially  established  for  purposes  of  de- 
scription, they  are  not  separated  in  nature,  but  merge  imperceptibly 
into  one  another.  Even  the  appearance  of  the  eruption  cannot  be  said  to 
begin  a  distinct  period  in  the  clinical  history  of  typhus  fever,  for  the 
other  symptoms  are  with  that  event  commonly  not  modified;  they  are 
only  deepened. 

The  attack  is  occasionally  preceded  by  prodromes  of  a  few  days'  dura- 
tion. They  consist  of  a  general  feeling  of  weakness  and  indisposition, 
with  headache,  loss  of  appetite,  nausea,  and  restlessness  at  night.  These 
prodromic  symptoms  are  not,  as  a  rule,  so  severe  as  to  compel  the  patient 
to  abandon  at  once  his  usual  occupations;  in  some  instances,  however,  he 
feels  so  dispirited  and  his  sense  of  fatigue  is  so  great,  that  even  in  this 
stage  he  promptly  betakes  himself  to  his  bed. 

Ill  the  greater  number  of  cases,  and  especially  in  those  cases  where  the 
development  of  the  fever  is  rapid  and  the  symptoms  are  severe,  prodromes 
are  wholly  absent. 

A  chill  or  chilliness  marks  the  invasion  of  the  disease,  which  is  gener- 
ally so  sudden  that  the  patient  or  his  friends  are  able  to  designate  the 
day  on  which  the  attack  began.  The  chill  or  chilly  sensations  are  in 
many  cases  repeated  at  irregular  intervals  during  the  first  two  or  three 
days,  and,  being  followed  by  perspiration,  may  present  a  superficial  like- 
ness to  intermittent  feyer.  In  children  not  infrequently,  but  rarely  in 
adults,  vomiting,  often  repeated  during  the  first  few  days,  attends  the 
onset.  At  the  same  time  there  is  fever,  which  rapidly  augments;  the  skin 
is  hot,  the  face  flushed,  the  eyes  injected;  headache  is  constant  and  se- 
vere, and  a  feeling  of  dulness  and  confusion,  with  vertigo  upon  assuming 
the  upright  posture,  and  noises  in   the   head,  distress  the  patient.     He 


Traite  de  pathologic  interne.     Tome  ii.     Paris,  1877. 


TYPHUS    FEVEK.  261 

complains  also  of  some  pain  in  the  back,  and  dull,  sore  pains  in  his  limbs 
and  joints.  Catarrhal  symptoms  are  common,  such  as  slightly  hurried 
respiration,  a  little  cough,  sore  throat,  swelling  of  the  edges  of  the  eye- 
lids, and  lachrymation. 

Muscular  weakness  and  an  extreme  sense  of  prostration  appear  early. 
The  patient's  face  at  first  wears  an  expression  of  weariness,  but  soon  be- 
comes dull  and  stupid.  He  falls  into  a  drows}^  state,  but  passes  uncom- 
fortable, restless  nig'hts.  Wakefulness  alternates  with  brief  periods  of 
sleep,  disturbed  by  painful  dreams  and  startings;  after  three  or  four  da^'s 
he  begins  to  talk  and  mutter  in  his  sleep,  and  between  sleep  and  waking 
there  is  slight  delirium.  When  awake,  the  patient  is  still  conscious  and 
answers  questions  slowly,  but  generalh'  with  correctness,  although  there 
is  confusion  of  mind  and  memory.  Already  he  requires  close  watching, 
especially  at  night,  when  in  his  delirium  he  may  leave  his  bed  and  wander 
from  the  room.  In  severe  cases  muscular  movements  are  early  unsteady 
and  tremulous,  the  tongue  trembles  as  it  is  protruded,  and  speech  is 
feeble  and  hesitating. 

From  the  beginning  the  tongue  is  large,  pale,  and  coated  at  first  with 
a  white,  later  with  a  thick,  yellowish  brown  fur;  it  speedily  shows  a  ten- 
dency to  become  brown  and  dry;  appetite  is  lost,  there  is  thirst,  the  se- 
cretion of  saliva  is  diminished,  taste  is  perverted,  and  a  stale,  unpleasant 
odor  loads  the  breath.  Nausea  is  occasionally  present,  but  vomiting  is 
rare.  There  is  constipation  as  a  rule,  but  in  some  instances  slight  diar- 
rhoea occurs.  The  abdomen  is  soft  and  painless,  with  the  exception  of 
slight  tenderness  in  the  region  of  the  liver  and  the  spleen.  Enlargement 
of  the  spleen  may  be  early  detected  on  percussion. 

The  pulse  is  increased  in  frequency  from  the  beginning  of  the  attack; 
it  soon  reaches  the  neighborhood  of  110  in  the  morning  and  runs  up  to 
130 — 130,  or  even  higher  in  the  evening,  with  a  much  higher  rate  in  chil- 
dren. It  is  full  at  first,  but  compressible — rarely  firm  or  tense;  it  soon 
grows  feeble,  but  dicrotism  is  uncommon. 

As  a  rule  the  temperature  rises  rapidly,  attaining  39.4° — 40°  C  (103° — 
104°  F.)  by  the  morning  of  the  third  or  fourth  day,  and  40°— 41°  C.  (104°— 
105.8°  F.)  the  same  evening,  and  remaining  nearly  stationary  at  these  points 
until  some  time  in  the  second  week.  The  high  temperatures  of  relapsing 
fever  are  very  rare  in  typhus.  '  An  evening  temperature  of  42°  C.  (107,6°  F.) 
is  seldom  observed.  A  decided  difference  between  the  morning  and  even- 
ing temperature  is  more  favorable,  even  when  the  evening  increase  is  con- 
siderable, than  a  continuously  high  temperature  range  in  which  the  morn- 
ing remission  fails. 

On  the  fourth  or  fifth  da}',  as  a  rule,  less  often  at  the  end  of  the  first 
week,  the  characteristic  eruption  appears.  It  consists  of  numerous  rose- 
ola-like spots  of  irregular  outline  and  varying  in  measurement  from  a  line 
to  three  or  four  lines  across,  scattered  singly,  like  the  spots  of  enteric 


2(32  THE    CONTINUED    FEVERS. 

fever,  or,  as  is  by  far  more  common,  arranged  in  irregular  groups,  like 
the  rash  of  measles.  At  first  these  spots  are  of  a  dirty  rose-color,  very 
sliohtly  raised  above  the  surface  of  the  surrounding  skin,  and  upon  pres- 
sure thev  momentarily  disappear.  AVithin  the  course  of  a  day  or  two 
they  become  darker  from  the  escape  of  the  coloring  matter  of  the  blood 
into  the  tissues;  they  are  no  longer  elevated,  but  appear  as  faint,  dirty 
brown  stains,  without  defined  margin,  and  fading,  not  disappearing,  upon 
pressure.  Not  infrequently,  at  a  later  period  of  the  fever,  petechias 
show  themselves  at  the  centre  of  many  of  these  spots,  while  others,  espe- 
cially in  grave  cases,  are  converted  into  dark  red  stains;  yet  they  cannot 
be  regarded  as  being  in  themselves  at  any  period  of  their  course  true 
petechia^.  They  closely  resemble  the  rose-rash  of  enteric  fever,  differing 
principally  in  their  numbers  and  grouping,  and  in  the  fact  that  they  ap- 
pear once  for  all,  and  not  in  successive  crops.  Their  course  is  typical. 
They  fade  during  the  first  half  of  the  second  week,  and  disappear  with  or 
without  desquamation  toward  its  close.  The  true  petechise  appear  as 
such  about  the  time  the  typical  rash  begins  to  fade,  that  is  to  say,  about 
the  eighth  or  tenth  day;  they  remain  longer  and  disappear  more  slowly. 
A  faintly  reddish,  ill-defined  mottling  or  marbling  of  the  skin  between  the 
spots  or  groups  of  spots,  which  form  the  characteristic  rash,  also  oc- 
curs to  a  greater  or  less  extent.  It  is  this  that  has  been  described,  from 
its  appearing  to  lie  beneath  the  surface,  as  the  "subcuticular"  eruption 
of  typhus.  The  appearance  of  the  rash  varies  greatly,  and  the  variation 
is  determined  by  the  general  abundance  of  the  two  eruptions,  by  the 
relative  preponderance  of  one  or  the  other,  and,  in  certain  cases,  by  the 
extent  of  the  true  petechiae,  which  are,  however,  frequently  absent  alto- 
gether. The  spots  and  the  mottlings  together  constitute  the  "  mulberry 
rash  "  of  Jeuner. 

The  distribution  of  the  typhus  eruption  is  irregular:  appearing  usually 
first  on  the  sides  of  the  chest  or  abdomen,  it  spreads  in  a  brief  time  over  the 
chest,  abdomen,  back,  and  limbs.  It  rarely  appears  upon  the  neck  or  face. 
It  has  in  some  instances  been  observed  to  first  appear  upon  the  backs  of  the 
Jiunds.  In  some  cases  the  roseola-like  rash  is  absent  altogether,  the  faint, 
subcuticular  mottling  alone  being  present.  An  entire  absence  of  erup- 
tion is  very  rare. 

About  the  end  of  the  first  week  the  depression  becomes  profound, 
headache  passes  into  delirium,  and  the  impairment  of  the  mental  powers 
is  extreme.  The  patient  is  dull  of  hearing;  he  answers  questions  very 
slowly  and  vaguely;  drowsiness  and  stupor  are  marked,  and  in  severe 
cases  there  is  a  tendency  to  coma.  The  character  of  the  delirium  is  vari- 
able. It  is  commonly  low,  wandering,  muttering;  occasionally  it  is  at 
first  acute,  severe,  boisterous.  This  violence  usually  soon  passes  away, 
leaving  the  patient  in  a  state  of  the  most  profound  exhaustion,  or  it  grad- 
ually subsides  into  dulness  with  muttering.     With  both  forms  of  delirium 


TYPHUS    FEVER.  2 Go 

there  is  sleeplessness.  The  tongue  is  now  dry,  fissured,  and  crusted, 
sordes  collect  upon  the  teeth  and  lips,  the  conjunctivse  are  deeply  in- 
jected, the  flushing  of  the  face  gives  place  to  a  dusky  pallor  most  marked 
about  the  nostrils  and  lips,  and  emaciation  progresses.  The  breath  and 
the  skin  exhale  a  peculiar  foetor,  there  is  annoying  cough  with  mucous 
expectoration,  and,  upon  auscultation,  rules  are  heard  in  all  parts  of  the 
chest.  Tlie  heart-sounds  and  the  impulse  are  faint  and  indistinct.  The 
area  of  splenic  dulness  is  considerably  extended.  The  state  of  the  bow- 
els varies  from  constipation  to  irregular,  scanty  dejections,  or  a  moderate 
intestinal  catarrh;  the  urine  is  scanty,  opaque,  high-colored,  and  very  fre- 
quently contains  albumen.  In  severe  cases  the  discharges  are  passed  in- 
voluntarily, or  there  is  retention  of  urine. 

The  symptoms  deepen.  The  patient  utters  no  complaint.  Neither 
pain  nor  headache  are  felt.  Appetite  is  completely  lost,  thirst  no  longer 
distresses  him,  although  he  swallows  with  difficulty,  owing  to  the  dryness 
of  his  throat.  He  lies  upon  his  back,  stupid,  lost,  utterly  indifferent  to 
everything  around  him,  sometimes  moaning  or  muttering  incoherently, 
sometimes  quiet.  The  eyelids  are  partly  closed,  the  pupils  contracted. 
Deafness  is  often  present.  When  spoken  to  loudly,  he  stares  vacantly 
without  attempting  a  reply.  If  asked  to  put  out  his  tongue,  he  opens  his 
mouth  and  leaves  it  open  till  reminded  to  close  it.  He  is  unable  to  raise 
himself,  or  even  to  turn  from  side  to  side;  from  muscular  weakness  he  is 
continually  sliding  down  in  the  bed;  his  hands  tremble,  he  picks  at  the 
bed-clothes  and  feebly  grasps  at  unseen  objects  in  the  air;  there  is  subsul- 
tus.  The  pulse  is  small  and  weak,  often  difficult  to  count,  less  commonly 
irregular  or  intermittent.  It  ranges  from  112  to  140  or  over.  The  por- 
tions of  the  skin  subjected  to  pressure  show  a  tendency  to  slough.  The 
surface  now  becomes  cooler  and  is  often  moist.  If  petechiie  are  present 
they  become  more  numerous. 

Death  may  take  place  at  any  time  after  a  condition  such  as  has  been 
described  becomes  fully  developed.  In  very  severe  cases  it  may  occur  in 
the  course  of  a  few  days  or  before  the  end  of  the  first  week.  More  com- 
monly the  fatal  termination  takes  place  between  the  tenth  and  the  seven- 
teenth days.  Death  at  a  later  period  is  uncommon,  except  as  a  conse- 
quence of  complications.  The  mode  of  death  is  by  coma,  or  by  asphyxia 
in  consequence  of  sudden  pulmonary  enlargement,  or  by  failure  of  the 
heart,  the  pulse  becoming  imperceptible,  the  surfaces  cold,  livid,  and  bathed 
in  sweat. 

In  abortive  cases  a  favorable  termination  may  take  place  by  critical  de- 
fervescence at  the  end  of  the  first  or  the  beginning  of  the  second  week. 

In  average  cases  the  fever  comes  to  an  end  about  the  fourteenth  day— 
sometimes  as  early  as  the  tenth  day,  sometimes  as  late  as  the  middle  of 
the  third  week.  The  amendment  is  more  or  less  sudden.  The  tempera- 
ture, which  in  many  cases  shows  a  little  abatement  for  some  days  before 


204  THE  CONTINUED  FEVERS. 

tlie  crisis,  falls  iu  a  single  niglit,  uv  in  the  course  of  twenty-four  or  forty- 
eight  hours,  to  the  normal  or  even  a  little  below  it;  the  pulse  beqpmes 
much  slower  and  its  character  improves;  the  stupor  and  coma  immediately 
disappear  after  a  prolonged,  refreshing  sleep,  out  of  which  the  patient 
awakes  as  from  an  oppressive  dream — conscious,  but  at  first  bewildered 
and  confused.  The  eruption  fades  and  gradually  disappears,  the  tongue 
cleans  and  becomes  moist  at  its  edges,  the  appetite  returns.  The  crisis  is 
often  attended  by  moderate  sweating  or  diarrhoea,  or  both,  and  by  an  in- 
crease in  the  amount  of  urine,  with  a  copious  deposit  of  urates  and  the 
disappearance  of  albumen.  In  the  course  of  a  few  days  the  tongue  is 
moist,  the  appetite  eager,  strength  begins  to  return,  and  the  convalescence 
progresses  rapidly,  so  that  many  patients  are  able  to  resume  their  work 
within  a  month  from  the  beginning  of  the  attack. 

Temporary  loss  of  hair  not  infrequently  occurs  during  convalescence, 
and  in  many  cases  a  considerable  length  of  time  ensues  before  the  body- 
weight  and  the  original  vigor  of  mind  are  regained.  The  deafness  in  al- 
most all  cases  gradually  passes  away. 

Relapses  occur,  but  they  are  much  less  common  in  typhus  than  in 
enteric  fever. 

Analysis  of  the  Principal  Symptoms, 
symptoms  eeferable  to   the  nekvous   system. 

A  chill  or  chilliness  is,  in  many  cases,  the  initial  symptom.  It  is,  how- 
ever, often  absent. 

Headache  is  among  the  earlier  and  more  constant  symptoms  of 
typhus.  When  prodromes  are  present,  headache  is  usually  among  the 
number.  In  most  cases  it  is  present  from  the  onset;  it  is  most  severe 
during  the  first  week;  it  often  lasts  only  a  few  days,  and,  as  a  very  general 
rule,  terminates  early  iu  the  second  week,  upon  the  advent  of  delirium. 
Its  seat  is  most  frequently  in  the  forehead  or  temples;  it  is  rarely  con- 
fined to  the  vertex  or  occiput;  in  a  majority  of  cases  it  is  general.  It  is 
usually  dull  or  heavy,  often  moderately  intense,  and  for  a  few  days  the 
most  prominent  symptom  of  the  disease,  but  rarely  acute  or  paroxysmal. 
Sometimes  it  is  slight. 

Vertigo,  increased  upon  assuming  the  upright  posture  and  becoming 
more  marked  with  the  progress  of  the  disease,  is  usually  associated  with 
the  headache. 

Pains  in  the  back  and  limbs  are  prominent  symptoms  during  the  earl^ 
days  of  the  attack.  The  pain  in  the  back  is  dull  and  heavy,  but  less  dis- 
tressing than  the  headache  or  the  pains  in  the  extremities.  The  last  ar(v 
described  as  of  a  sore  character,  as  if  from  severe  bruises;  they  outlast 
both  the  headache  and  back-pains,  and  often  recur  during  convalescence. 
They  not  infrequently  implicate  the  joints  as  well  as  the  muscular  masses. 


TYPHUS    FEVKli.  265 

Dellriuin  is  common.  Some  impairment  of  the  mental  faculties  is 
constant  ;  hence  the  synonym  "  brain  fever."  In  the  latter  part  of  the 
iirst  week,  as  a  general  rule,  sluggishness  of  mind  becomes  apparent;  tlie 
perceptions  are  blunted,  mind  and  memory  are  confused;  the  patient  can- 
not tell  how  long  he  has  been  sick,  nor  the  day  of  the  week  ;  he  is  indif- 
ferent to  what  goes  on  around  him,  and  annoyed  at  being  spoken  to  or 
questioned.  This  mental  dulness  alternates  with  drowsiness,  which  lacks 
the  refreshing  attributes  of  sleep  and  scarcely  deserves  the  name.  He 
becomes  more  and  more  dull,  and,  although  this  degree  of  mental  dis- 
turbance may  not  be  exceeded  in  mild  cases,  in  most  instances  the  stupor 
passes  into  delirium. 

The  period  at  which  delirium  supervenes  is  variable.  It  commonly 
appears  as  the  headache  subsides — about  the  end  of  the  first  or  the  begin- 
ning of  the  second  week.  It  may  occur  much  earlier.  In  rare  instances 
it  has  been  observed  from  the  first  night  of  the  attack;  on  the  other  hand, 
it  may  not  appear  till  shortly  before  the  critical  defervescence,  toward 
the  close  of  the  second,  or  in  the  early  part  of  the  third  week  in  protracted 
cases. 

At  first  the  delirium  occurs  only  during  some  part  or  the  Avhole  of  the 
night,  and  is  absent  during  the  day,  to  return  again  at  nightfall.  After  a 
time,  it  becomes  present  during  the  day  also,  and  is  then  worse  by  night. 
It  is  common  for  patients  to  be  drowsy  and  stupid  in  the  daytime,  wake- 
ful and  delirious  at  night.  It  usually  ceases  after  the  crisis,  but  in  rare 
cases  continues  to  occur  at  nig-ht  for  some  time  into  the  convalescence, 
even  after  the  general  condition  has  begun  to  show  a  decided  improve- 
ment. 

The  character  of  the  delirium  presents  the  widest  range  of  variation. 
This  phenomenon,  as  well  as  the  other  symptoms  of  mental  disturbance, 
are  greatly  modified  by  the  mental  temperament  of  the  individual,  his 
intelligence  and  education,  previous  habits  of  intemperance  and  the  like, 
and  Ijy  the  amount  of  anxiety  and  fatigue  that  have  preceded  the  attack. 

In  uncomplicated  cases  the  severity  of  the  attack  may  be  measured  by 
the  degree  of  mental  aberration  and  delirium  (Murcliison). 

The  delirium  is  generally  quiet;  the  patient  moans  and  mutters  inco- 
herently, or  he  is  restless,  irritable,  and  easily  disturbed.  At  first,  he 
replies  coherently  to  questions  when  aroused,  or  his  answers  are  rambling 
and  inconsequent;  after  a  time  he  falls  into  a  state  of  more  or  less  com- 
plete unconsciousness. 

It  is  less  frequently,  but  in  no  small  proportion  of  cases,  much  like 
tliat  of  chronic  alcoholism — a  form  of  delirium  tremens.  In  spite  of  his 
extreme  prostration,  the  patient  is  restless  and  fidgety;  he  sleeps  little 
or  not  at  all;  he  glances  furtively  from  side  to  side,  and  makes  eager  but 
]>.!rposeless  attempts  to  leave  his  bed  ;  his  tongue  is  protruded  trem- 
blingly, and  there  are  muscular  tremors  of  his  limbs.      The  pulse  is  weak 


266  THE    CONTINUED    FEVERS. 

and  frequent,  the  impulse  and  first  heart-sound  impaired,  and  the  skin 
lealvV. 

Again,  the  delirium  may  be  active  and  noisy.  The  patient  shouts  and 
screams.  lie  tosses  about  and  seeks  with  violent  efforts  to  get  out  of 
bed.  His  strenirth  is  surprising.  He  has  to  be  controlled  Ijy  force,  for 
which  stout  attendants  are  sometimes  necessary.  In  this  state  tlie 
patients  often  show  a  suicidal  disposition,  and  require  careful  watching-, 
especially  at  night.  Indeed,  the  mental  state  in  typhus  fever  is  so  pecu- 
liar, that  it  is  in  no  case  safe  to  leave  tlie  patient  alone.  Patients  who 
are  quite  rational  to  all  appearances  during  the  day,  rnay  wander  about 
in  delirium  at  night,  and  the  semblance  of  reason  at  one  period  of  the 
day  may  be  followed  by  suicidal  mania  in  the  course  of  a  few  hours.  The 
last  form  of  delirium  is  called  delirium  ferox  j  it  is  much  less  common 
in  typhus  than  the  low,  wandering  form  which  has  been  called  "  typho- 
mania,"  and  is  apt  to  be  more  or  less  transient  and  to  terminate  in  pro- 
found exhaustion  or  even  fatal  collapse;  in  other  cases  it  subsides  into 
typhomania. 

The  mental  state  is  peculiar,  but  that  it  difiers  essentially  from  that 
of  the  delirium  in  other  fevers  or  acute  diseases  is  not  apparent.  Dr. 
Murchison  has  collected,  in  "  The  Continued  Fevers,"  an  interesting  ac- 
count of  the  delusions  and  fancies  of  patients  in  the  delirium  of  typhus,  to 
which  the  reader  interested  in  this  branch  of  the  subject  is  referred.  The 
instances  cited  bear  out  the  statement  of  Griesinger,'  that  the  mind  in 
the  delirium  of  typhus  is  very  often  concerned  with  a  limited  number  of 
constantly  recurring  alarming  fancies. 

Da  Costa  observed  a  fatal  case  in  the  wards  of  the  Pennsylvania  Hos- 
pital, in  which  delirium  was  absent  altogether.  The  patient's  mind  re- 
mained clear  to  the  last  hours  of  life. 

IVakefuhiess,  drowsiness. — During  the  first  two  or  three  days  the 
patient  may  be  dull  and  inclined  to  sleep,  but  wakefulness  is  a  j^rominent 
and  distressing  symptom  in  most  cases  until  the  beginning  or  middle  of 
the  first  week,  particularly  at  night.  Inability  to  sleep  and  restlessness 
are  also  common  in  children.  It  is  a  curious  fact,  noted  by  many  ob- 
servers, that  patients  who  sleep  sometimes  for  several  hours  together,  will 
often  insist  that  they  have  not  closed  their  eyes,  although  in  all  other 
respects  rational. 

To  this  sleeping,  without  being  aware  of  it  afterward,  has  been  ap- 
plied the  awkward  and  useless  term  coma  vigil.  This  term  has  also  been 
applied,  perhaps  more  correctly,  to  a  condition  of  great  gravity,  "  in  which 
the  patient  lies  with  his  eyes  wide  open,  g-azing-  into  vacuity,  his  mouth 
partially  open,  his  face  pale  and  devoid  of  expression  ;  the  pulse  rapid  and 
feeble,  or  imperceptible;  the  breathing-  scarcely  perceptible;   and  the  skin 


'  Virchow's  Handbuch.    P.and  II.,  Abtheil.  2.     Erlangen,  1804. 


TYPHUS    FEVER.  267 

cold  and  bathed  in  perspiration.  He  is  evidently  awake,  but  he  is  indif- 
ferent and  absolutely  insensible  to  all  that  is  going'  on  about  him."  The 
condition  so  graphically  described  by  Jenner  is  not  infrequently  observed 
shortly  before  the  fatal  issue  in  typhus.  The  term  coma  vigil  is  not 
sufficiently  significant  to  describe  it,  nor  is  it  sufficiently  explicit,  being 
indiscriminately  applied  to  two  widely  different  states,  to  designate  either 
the  one  or  the  other.  It  belongs  to  a  larg-e  class  of  meaninsjless  words 
which,  being  neither  descriptive  nor  explicit,  nor  generally  understood 
or  understandable,  might  well  be  sj^ared  out  of  medical  literature,  which 
they  cumber. 

J)roicsiness,  more  or  less  marked,  not  infrequently  alternates  with 
wakefulness  and  delirium;  bvit  about  the  middle  of  the  second  week  that 
indeterminate  condition  between  sleep  and  waking,  to  which  the  term 
somnolence  has  been  a2:)plied,  commonly  supervenes.  It  may  follow  pro- 
longed wakefulness  and  mental  excitement,  or  may  occur  without  them.. 
It  is  more  or  less  profound  according  to  the  gravity  of  the  case,  and 
deepens  by  imperceptible  gradations;  first  into  stupor,  then  to  coma. 

Debility  is  one  of  the  most  characteristic  features  of  typhus.  It 
comes  on  early,  and  is  in  all  cases  marked.  The  patients  are  obliged  to- 
take  to  their  beds  from  sheer  weakness  within  the  first  day  or  two  of  their 
illness.  So  great  is  the  loss  of  muscular  power  that  the  patients  are  un- 
able to  walk  or  rise  without  assistance,  or,  in  many  cases,  even  to  turn 
in  bed.  As  a  general  rule,  the  prostration  increases  till  the  ninth  or 
twelfth  day,  when  it  is  often  complete.  The  excessive  effort  of  the 
maniacal  paroxysms  in  the  acute  form  of  delirium  is  apt  to  be  followed  by 
a  corresponding  prostration,  so  great  in  some  instances  as  to  prove 
rapidly  fatal.  The  loss  of  strength  sometimes  is  not  very  great  until  the 
beginning  of  the  second  week  of  the  disease,  when  it  develops  suddenly 
with  dangerous  symptoms  of  extreme  debility.  This  class  of  cases  is 
rare. 

Except  when  changed  by  restlessness  or  delirium,  the  attitude  of  the 
patient  is,  by  reason  of  the  loss  of  muscular  power,  that  which  is  described 
as  the  dorsal  decubitus.  With  increasing  weakness  he  tends  to  sink 
toward  the  foot  of  the  bed. 

Paralyses  of  certain  groups  of  muscles  occur;  hence  the  involun- 
tary discharges  and  the  retention  of  urine  that  so  often  attend  the  height 
of  the  disease.  Dribbling  of  urine  may  result  not  only  from  paralysis  of 
the  neck  of  the  bladder,  but  it  may  also  arise  as  a  consequence  of  over- 
distention  of  the  bladder  from  paralysis  of  its  muscular  coat.  In  typhus 
and  in  all  low  fevers,  the  routine  exploration  of  the  suprapubic  region  by 
palpation  and  percussion  is  imperative,  as  in  this  way  retention  of  urine, 
that  by  reason  of  the  dribbling  might  be  otherwise  overlooked,  is  often 
detected,  and  may  be  relieved  by  the  use  of  the  catheter.  Neglect  of 
this  precaution  is  apt  to  result  in  ura?mia  with  coma  and  convulsions,  or. 


208  THE    CONTINUED    FEVEKS. 

more  remotely,  in  catarrh  of  the  bladder  or  ulceration  of  its  mucous  mem- 
brane. 

Murchison  states  that  there  is  occasional  paralysis  of  the  orbiculares 
muscles,  and  that,  in  consequence  of  the  inability  to  close  the  eyes,  vilcer- 
ation  and  sloughing-  of  the  cornea  may  take  place. 

Among  the  disturbances  of  the  functions  of  the  nervous  system  is 
tremulousness.  In  few  severe  cases  is  trembling  of  the  hands  and  tongue 
wholly  absent  during  the  period  preceding  the  crisis  or  the  fatal  issue.  In 
some  cases  —  especially  in  those  who  have  habitually  indulged  too  freely 
in  the  abuse  of  alcohol,  the  aged  and  the  very  infirm,  the  whole  body  is 
observed  to  be  in  a  state  of  tremor.  Oscillatory  motions  of  the  eyeballs 
(nystagmus)  and  choreic  movements  of  the  limbs  have  been  recorded. 
Subsultus  tendinum,  spasmodic  twitchings  of  the  muscles  of  the  face, 
carphology  or  grasping  in  the  air,  and  picking  at  the  bed-clothes,  also 
belong  to  the  motor  disturbances  of  the  gravest  cases  of  typhus.  Hic- 
cough occasionally  occurs. 

Much  more  rarely,  and  in  grave  cases  only,  tense  contractions  of  groups 
of  muscles  are  met  with.  The  flexors  of  the  forearm,  and  of  the  thighs  and 
legs,  are  among  the  groups  apt  to  be  thus  affected.  Trismus,  strabismus, 
and,  in  very  rare  instances,  opisthotonus,  have  been  seen. 

General  eonvrdslons  are  met  with,  according  to  Murchison,  about  once 
in  one  hundred  cases.  They  are  due  to  uraemia  in  the  vast  majority  of 
cases,  and  rarely  appear  earlier  than  the  middle  or  end  of  the  second 
week.  An  unusual  tendency  to  stupor,  and  a  marked  diminution  in  the 
quantity  of  urine  secreted,  as  a  rule,  precede  for  three  or  four  days  the 
fit,  which  is  apt  to  be  followed  by  death,  or  by  coma  that  continues  till 
death  occurs.  Life  is  rarely  jDrolonged  beyond  three  or  four  days  after 
the  occurrence  of  general  convulsions.  Fatal  ur^emic  convulsions  mav, 
however,  occur  in  cases  that  have  apparently  pursued  a  mild  course,  or 
even  after  the  patient  has  entered  the  stage  of  convalescence. 

The  organs  of  special  sense  are  to  some  extent  implicated  in  the 
processes  of  typhus.  During  the  first  week  the  eyes  are  watery;  later  in 
the  course  of  the  attack  they  are  dry.  The  conjunctivae  are  commonly 
deeply  injected  from  the  earliest  days  of  the  attack.  Most  observers  in- 
sist upon  the  fact  that  the  discoloration  of  the  conjunctiva  is  of  a  darker 
hue  in  typhus  than  in  ordinary  inflammations  of  the  eye.  The  pupils  are 
commonly  contracted,  sometimes  in  grave  cases  to  a  mere  point,  and  are 
not  infrequently  insensible  to  the  stimulus  of  light.  Dilatation  of  the 
pupils,  with  failure  to  respond  to  light,  is  very  rare,  and  occurs  only  in  the 
most  profound  stupor  or  coma.      Intolerance  of  bright  light  is  common. 

During  the  first  four  or  five  days,  patients  very  often  complain  of 
noises  in  the  head,  and  associate  them  with  dizziness.  After  the  fourth 
or  fifth  day,  decided  or  even  complete  deafness  is  common;  it  often  ex- 
tends into  the  convalescence,  but  is  not  persistent.     It  was  regarded  as  a 


TYPHUS    FEVEK.  269 

favorable  symptom  by  the  earlier  observers.  This  opinion  is  not  borne 
out  by  recent  observations.  It  is  not  a  nervous  symptom,  but  is  probably 
due  to  catarrhal  processes  in  the  middle  (or  external)  ear.  Intolerance  of 
sound  is  far  less  common. 

Coryza  forms  part  of  the  general  catarrhal  disturbance  which  attends 
the  development  of  typhus. 

Epistaxis  is  very  rare  in  most  epidemics  of  typhus.  Most  writers  do  not 
allude  to  it.  Murchison  met  with  it  in  about  a  dozen  instances  out  of  seven 
thousand  cases;  Barrallier  97  times  in  1,302  cases,  and  Jacquot  in  about 
one-fourth  the  cases  among  the  troops  in  the  Crimea,  where,  however, 
typhus  was  very  often  complicated  with  scurvy.  On  the  other  hand,  it 
was  present  in  one-fourth  the  cases  observed  in  Philadelphia  by  Da  Costa, 
who  states  that  hemorrhages  from  other  sources,  as  the  gums  or  bowels, 
did  not  occur  in  his  cases,  and  that  sordes  were  not  unusually  common. 
When  epistaxis  is  present,  it  comes  on  early,  and  the  cases  in  which  it  oc 
curs  are,  for  the  most  part,  severe. 

The  taste,  as  in  all  fevers,  is  perverted.  Sweet  things  are  disliked; 
acids  are  often  grateful. 

The  general  sensibility  of  the  surface  is  not  infrequently  increased. 
It  is  important  to  distinguish  between  hypersesthesia  of  the  surface  of 
the  abdomen  and  tenderness  of  the  internal  organs  upon  pressure. 
Toward  the  close  of  grave  cases,  general  anaesthesia  is  said  to  be  some- 
times present.  The  mental  state  of  such  patients  renders  this  observation 
in  most  cases  doubtful. 

THE  PHENOMENA  OF  THE  FEVEB. 

The  tem'perature  range  of  typhus,  as  Lebert  has  pointed  out,  lies  mid- 
way between  that  of  enteric  and  that  of  relapsing  fever.  With  the 
former  it  shows  a  rapid,  progressive  increase  of  body-heat  during  the  first 
days  of  the  attack,  and  a  continuous  high  range  marked  by  moderate 
morning  remissions.  The  range  of  typhus,  however,  differs  from  that  of 
enteric  fever  in  the  much  more  rapid  rise  to  its  maximum,  the  shorter 
duration  of  high  temperature,  the  marked  fluctuations  early  in  the  second 
week,  and  its  critical  termination. 

The  curve  of  typhus  resembles  that  of  relapsing  fever  in  that  both  rise 
rai:)idly  to  the  maximum  at  the  outset,  remain  continuously  high,  and  ter- 
minate abruptly.  The  rise  in  relapsing  fever  is,  however,  much  more 
abrupt,  the  range  higher,  the  course  shorter,  and  the  crisis  on  the  fifth  or 
seventh  day  more  precipitous.  In  no  case  does  typhus  show,  after  an  in- 
termission of  several  days,  the  sudden,  intense,  febrile  relapse  Avhich  is 
characteristic  of  relapsing  fever. 

Considerable  discrepancies  are  apparent  upon  an  examination  of  the 
records  of  the  studies  made  by  many  competent  observers  on  the  tempera- 


270  THE    CONTINUED    FEVEKS. 

tare  of  typhus.  Doubtless  some  of  the  statements  made  are  based  upon 
too  limited  a  number  of  observations,  possibly  others  are  the  result  of 
tlie  investigation  of  cases  in  which  the  typhus  temperature  has  been  modi- 
fied by  complications,  or  other  sources  of  error  may  have  been  overlooked. 
It  is,  however,  probable  that  the  discrepancies  in  the  records  of  different 
observers  are  due  in  great  part  to  differences  in  the  temperature  range  of 
typhus  in  different  epidemics. 

Without  going  into  a  detailed  comparison  of  the  recorded  observa- 
tions, we  may  regard  the  following  statements  as  representing  the  main 
facts. 

The  temperature  rises  rapidly  from  the  onset  of  the  disease,  and  in 
average  cases  reaches  its  maximum  at  from  the  fourth  to  the  seventh  day, 
or  about  the  period  of  the  appearance  of  the  eruption.  Occasionally,  the 
maximum  is  attained  as  early  as  the  third  day,  or,  and  this  is  especially 
so  in  very  severe  cases,  not  until  the  ninth  or  tenth  day.  The  maximum 
is  commonly  between  40°— 41°  C.  (104°— 105.8°  F.);  it  rarely  reaches 
41.5°  C.  (106.7°  F.),  except  in  children,  and  it  may  not  exceed  39.5°  C. 
<103.1°  F.) 

Even  on  the  l^rst  evening  it  may  reach  40°— 40.5°  C.  (104°— 104.9°  F.). 
On  the  evening  of  the  fourth  day  it  is  seldom  below  40.5°  C.  (104.9°  F.), 
much  more  commonly  41°  C.  (105.8°  F.),  and  not  rarely  higher,  while  the 
average  morning  temperature  at  this  period  is  39.5° — 40°  C.  (103.1° — 
104°  F.).  Exceptionally,  an  evening  temperature  of  39°  C.  (102°  F.)  has 
been  encountered  on  the  third  day;  but  this  is  not  of  itself,  by  any  means, 
of  favorable  prognostic  import. 

After  reaching  its  maximum,  the  temperature  falls  off*  to  a  very  slight 
•extent  in  about  two-thirds  the  cases,  but  remains  about  the  same  in  the 
rest,  and  there  is  otherwise  little  change  for  several  days,  until  about  the 
seventh  or  eighth  day — more  rarely,  as  late  as  the  tenth,  when  there  is 
■commonly,  except  in  the  severe  cases,  a  slight  remission,  which,  in  the  very 
mild  cases,  may  be  followed  by  complete  defervescence,  but  after  which 
the  temperature  commonly  rises  again,  and  then  gradually  but  slowly  falls 
until  the  twelfth  or  fourteenth  day,  when  it  rapidly  subsides  to  the  nor- 
mal, or  in  many  instances  even  slightly  below  it. 

The  morning  remissions  are  less  marked  than  in  enteric  fever;  they 
vary  from  one  day  to  the  next,  but  the  usual  difference  is  0.5° — 1°  C.  (0.9" 
— 1.8°  F.)  for  the  second  week,  though  the  same  curve  may  show  greater 
or  less  variations,  especially  as  the  period  of  the  crisis  draws  near.  Ex- 
cept during  defervescence,  a  higher  morning  than  evening  temperature  is 
very  rare.  A  curve  in  which  the  morning  fall  is  absent  may  be  looked 
upon  as  an  unfavorable  indication,  and  the  same  may  be  said  of  a  sudden 
fall  of  temperature,  with  arise  in  the  pulse  or  without  improvement  in  the 
•other  symptoms.  A  high  range  of  temperature  in  the  first  week  is  apt 
to  be  followed  by  severe  cerebral  symptoms  in  the  second.     The  absence 


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LM'  THE    CONTINUED    l-'EVEKS. 

oE  a  distinct,  tlioug-li  slight   n^inission,  about  the  seventh   or  eighth  day, 
is  of  unfavorable  prognosis. 

A  fall  of  temperature  before  the  crisis  is  common.  This  fall  usually  oc- 
curs in  the  morning  of  the  day  preceding  the  crisis.  It  may  amount  to  1.5'' 
—3°  C.  (2.7°— 3.0°  F.),  or  even  to  2.5°  C.  (4.5°  F.),  but  the  temperature  rises 
again  in  the  evening,  to  fall  permanently  on  the  following,  the  critical  day. 
In  rarer  cases  a  decided  rise,  amounting  to  2° — 2.5°  C.  (3.0° — 4.5°  F.)  pre- 
cedes the  crisis,  and  there  are  cases  in  which  a  gradual  abatement,  with  a 
progressively  lower  morning  and  evening  temperature  from  day  to  day, 
occurs.  Finally,  there  are  cases  in  which  no  change  in  temperature,  pre- 
cedes the  crisis,  which  sets  in  suddenly  and  progresses  with  rapidity. 

The  critical  defervescence  may'  be  completed  within  twelve  hours. 
Much  more  commonly  it  occupies  one,  two,  or  even  three  days.  It  usually 
begins  in  the  evening,  only  exceptionally  during  the  course  of  the  day'- 
The  fall  in  temperature  amounts  to  2°— 4°  C.  (3.0°— 7.2°  F.). 

Recovery  commonly  takes  place  after  the  crisis;  but  in  some  instances 
the  patients  have  fallen  into  fatal  collapse  after  it,  or  death  may  occur  in 
consequence  of  some  complication. 

The  fall  is  usually  to  the  normal,  but  not  infrequently  to  a  point  a 
little  below  it,  36.5°— 30°  C.  (97.7°— 90.8°  F.).  The  evening  after  the 
lowest  point  is  reached  there  is  usually  a  slight  rise,  to  be  followed  by  a 
fall  to  below  the  normal  the  following  day',  and  a  subnormal  temperature 
is  often  present  for  several  days  in  the  convalescence,  liable,  however,  to 
occasional  transient  subfebrile  exacerbations  in  consequence  of  complica- 
tions, or  without  assig-nable  cause. 

In  very  rare  instances  an  attack  of  typhus  has  been  protracted  into 
the  third  or  fourth  week,  coming  slowly  to  an  end  by  true  lysis. 

A  rise  in  temperature  of  from  1,5° — 3.0°  0,  (2,7° — 0,4°  F.)  takes  j)lace 
just  previous  to,  or  at  the  time  of  death,  in  uncomplicated  cases. 

The  pulse  from  the  beginning  of  the  attack  is  frequent,  varying  be- 
tween 110  and  130,  and  keeping  pace  with  the  severity  of  the  general 
symptoms,  and  in  the  main  with  the  temperature  range.  The  evening 
rate  is  usually  slightly  in  excess  of  the  morning,  and  the  daily'  variations 
are  inconsiderable.  Sometimes  it  increases  from  day  to  day  until  death 
or  recovery.  Although  a  rapid  pulse  is  commonly  present  in  severe  cases, 
a  slow  pvilseis  by  no  means  invariably  the  indication  of  a  mild  case.  The 
pulse  is  sometimes  slow  in  cases  characterized  by  extreme  prostration, 
and  death  has  taken  jiluce  in  cases  in  which  the  pulse  at  no  time  exceeded 
100    (Murchison), 

A  gradual  at  first,  but  toward  the  end  of  the  defervescence  a  rapid  fall 
in  the  pulse-rate,  is  commonly  the  attendant  sy^mptom  of  improvement. 
With  a  temperature  below  the  normal,  in  the  first  days  of  convalescence, 
there  is  usually  a  pulse  lower  than  normal  in  frequency  (50 — 70).  If  it 
remain  frequent,  particularly  while  the  patient  is  in  bed  and  quiet,  this 


TYPHUS    FEVEE. 


273 


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274  THE    CONTINUED    FEVERS. 

may  be  in  consequence  of  some  complication;  and  a  decided  rise,  after  it 
has  fallen  with  the  temperature,  is  almost  always  indicative  of  a  compli- 
cation, which  is  often  pulmonary. 

During  the  second  week,  if  the  depression  be  very  great,  the  frequency 
of  the  pulse  may  be  accelerated,  while  the  temperature  is  slightly  lowered; 
but,  upon  the  Avhole,  the  pulse  increases  in  frequency  as  the  temperature 
rises,  and  falls  with  the  defervescence. 

In  the  beginning  of  the  attack  the  pulse  is  full,  soft,  and  compressible  ; 
in  young  and  vigorous  persons  it  may  for  a  time  be  somewhat  tense,  as 
■well  as  full,  but  this  is  highly  uncommon.  As  the  disease  progresses  and 
the  strength  of  the  patient  becomes  from  day  to  day  more  impaired,  the 
pulse  diminishes  in  force  as  it  rises  in  frequency,  becoming  smaller  and 
weaker,  until  at  length  it  is  perceived  with  difficulty,  or  not  at  all.  This 
feeble  pulse  of  typhus  is  not  only  greatly  modified  in  frequency,  but  also 
in  force  by  changes  from  the  horizontal  to  the  semi-erect  or  erect  posi- 
tion, both  during  the  fever  and  in  the  convalescence.  It  is  not  rarely 
irregular  or  intermitting,  often  undulatory,  but  less  commonly  dicrotous 
in  typhus  than  in  enteric  fever. 

The  impulse  of  the  heart  is  almost  invariably,  except  in  the  mildest 
cases,  enfeebled  from  the  fifth  or  sixth  day  of  the  disease.  This  enfeeble- 
ment  is  progressive,  and  for  several  days  during  the  height  of  the  disease 
the  impulse  is  not  infrequently  absent  altogether.  Coincidently  with  the 
diminution  of  the  impulse,  the  first  sound  becomes  progressively  less  dis- 
tinct, and  may  at  last  be  inaudible.  It  is  occasionally  replaced  by  a  soft, 
systolic  murmur  of  ha?mic  origin.  The  second  sound  remains  distinct. 
With  convalescence,  the  impulse  and  the  cardiac  first  sound  only  gradually 
regain  their  normal  character. 

The  radial  pulse  is  not  always  in  correspondence  with  the  impulse  of 
the  heart  as  regards  force.  The  former  may  be  small,  weak,  or  even  im- 
perceptible, while  the  cardiac  impulse  is  excited  and  so  strong  as  to  dis- 
tress the  patient,  and  the  systolic  sound  but  little  enfeebled. 

These  phenomena  relating  to  the  heart  are  due  in  part  to  impaired 
innervation,  and  in  part  to  the  degenerative  changes  that  take  place  in 
the  muscular  tissue  of  the  organ.  They  are  of  the  utmost  importance 
clinically,  as  affording  the  most  reliable  guide  to  the  administration  of 
stimulants,  both  as  regards  the  time  and  the  amount. 

To  the  enfeeblement  of  the  circulation  so  characteristic  of  typhus 
are  to  be  referred  the  duskiness  and  lividity  of  the  face  and  extremi- 
ties, often  seen  in  the  fully  developed  disease,  the  tendency  to  venous 
and  arterial  thrombosis  described  in  rare  instances,  and  the  occurrence 
of  embolism  of  the  larger  arteries,  with  resulting  gangrene  of  an  ex- 
tremity. 

Theurlne  varies  in  quantity  with  the  amount  of  fluids  taken.  During 
the  first  week,  it  is  often  reduced  from  twenty-five  to  fifty  per  cent.     In 


TYPHUS    FEYEU 


275 

In 


the  later   periods   of  the   disease    it   is  not   infrequently   increased 
severe  cases  partial  or  total  suppression  may  occur. 

Notwithstanding  the  large  amount  of  water  drunk,  and  the  dryness  of 
the   skin  and   absence    of   diarrhcEa,  the  amount    of  urine   in    the    whole 


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course  of  the  disease  is  in  most  cases  decreased.  There  appears  to  be  a 
retention  of  water  in  the  system.  At  the  commencement  of  convales- 
cence the  secretion  is  often  greatly  augmented. 

It  is  commonly  high-colored  at  first;  it  may  remain  so  until  the  crisis. 


276  TllK    CONTINUED    FEVKi:S. 

As  lliu  quantity  increases,  either  jit  the  lieig'ht  of  tlie  attack  or  upon  the 
beginning-  of  convalescence,  the  urine  may  become  very  pale.  When 
partial  suppression  occurs,  it  is  often  of  a  dirty  brown  color  like  porter, 
M'lth  a  copious  deposit  of  renal  epithelium  and  blood-elements. 

The  specific  gravity  is  usually  high  in  the  beginning  of  the  attack,  and 
lower  later  In  its  course  and  in  convalescence,  varying  with  the  amount  of 
iirine  passed. 

Tlie  reaction  Is  at  first  decidedly  acid;  later  it  is  often  neutral,  or  even 
alkaline,  when  freshly  passed,  and  dej^oslts  an  abundance  of  urates  and 
l)hosphates. 

The  chlorides  gradually  lessen;  at  the  beginning  of  the  second  week 
they  are  reduced  to  a  trace,  or,  in  severe  cases,  are  altogether  absent. 
This  Is  not  wholly  due  to  the  non-ingestlon  of  salt,  since  in  health  all 
chlorides  may  be  withheld,  yet  for  a  considerable  time,  the  urine  will  con- 
tinue to  contain  them.  With  the  approach  of  convalescence  they  reappear 
in  some  quantity  in  the  urine  without  change  in  the  diet,  and  gradually 
increase  from  day  to  day.  Their  disappearance  is  due  to  the  processes 
of  the  fever,  and  takes  place  in  cases  uncomplicated  by  diarrhcea  or  by 
pneumonia. 

The  daily  excretion  of  urea  is  at  first  considerably  above  the  normal 
amount,  notwithstanding  the  decrease  in  the  quantity  of  food,  and  this 
increase  is  proportionate  to  the  intensity  of  the  fever  and  the  consequent 
tissue-waste.  The  increase  has  been  present  in  the  earliest  days  upon 
which  the  urine  has  been  examined.  The  daily  excretion  is  very  variable 
in  the  second  week.  In  some  cases  it  gradually  diminishes,  in  others  it 
remains  lilgli  until  the  crisis.  During  the  early  days  of  convalescence 
the  quantity  of  urea  falls  below  the  physiological  standard,  notwithstand- 
ing a  generous  diet,  and  gradually  I'lses  again  as  health  and  strength  are 
regained. 

Urea  has  been  repeatedly  found  In  the  blood  of  persons  who  have  died 
of  typhus,  with  marked  cerebral  symptoms,  even  although  there  have 
been  no  disease  of  the  kidneys  and  no  diminution  in  the  amount  of  urine 
(Murchison). 

TJric  acid  is  usually  increased. 

Alhuinen  has  been  found  to  be  present  in  the  urine  in  a  considerable 
proportion  of  cases,  by  all  observers  who  have  made  it  the  subject  of  in- 
vestigation. This  proportion  has  greatly  varied  in  different  epidemics; 
sometimes  constituting  the  greater  number  or  even  nearly  all  of  the  cases 
examined,  at  other  times  amounting  to  a  very  small  percentage  of  them. 
The  albumen  varies  In  amount  from  a  mere  trace  to  an  abundant  deposit; 
it  may  appear  early  In  the  attack,  or  not  until  a  day  or  two  before  the 
crisis;  and  finally,  it  is  often  transient,  lasting  at  the  most  three  or  four 
days,  sometimes  persistent  from  the  day  of  its  first  appearance,  commonly 
the  sixth   or  seventh  day  of  the  disease,  until  death  or  recovery.      The 


TYPHUS    FJ<:VER.  277 

cases  in  wliich  albuminuria  is  early,  or  copious  and  persistent,  arc  almost 
always  severe.  At  the  same  time  it  does  not  arise  as  a  symptom  in  xo.vy 
many  severe  or  even  fatal  cases.  The  albuminuria  of  typhus  is  due  to 
the  altered  condition  of  the  blood,  which  induces  hypentunia  of  the  kid- 
neys, that  may  proceed  to  actual  inflammation  of  their  stnuiture.  With 
the  albumen,  and  in  many  cases  when  its  presence  cannot  be  detected, 
renal  epithelium,  and  hyaline,  granular  and  epithelial  casts  are  found. 
Casts  are  more  frequently  jjresent  than  absent  in  the  urine  of  severe 
cases  (Da  Costa).  In  cases  of  gi-eat  severity,  blood  and  blood-casts  are 
met  Avitli.  After  death  the  kidneys  have  frequently  presented  the  ap- 
pearances of  acute  nephritis,  where  no  history  of  previous  reiuil  disease 
existed.  Previously  existing  nephritis,  in  a  limited  i^ropcu'tion  of  the 
cases,  will  account  for  the  albuminuria. 

Sugar  was  found  in  minute  amounts  in  the  urine  of  nine  out  of  four- 
teen typhus  cases,  in  which  it  was  soug'ht  for  by  Dr.  George  Buchanan, 
who  states  that  it  appeared  at  any  period  between  the  sixth  and  twenty- 
seventh  days,  and  only  lasted  a  day  or  two.  It  was  of  no  clinical  signi- 
ficance. 

SYMPTOJIS    MANIFESTED    UY    THE    SKTN. 

71ie  eru.ptio)i  of  typhus  is  prominent  among  the  clinical  phenomena  of 
the  disease.  It  is  very  rarely  absent.  The  statistics  of  the  London  Fever 
Hospital  show  that,  of  18,268  cases  admitted  to  that  institutioii  in  twenty- 
three  years,  the  eruption  was  noted  in  17,025,  or  in  9-3.2  per  cent.;  and  Dr. 
Murchison  informs  us  that  these  figui'es  exaggerate  the  proportion  of  the 
cases  in  which  it  was  absent,  it  being,  in  certain  cases  where  it  was  pres- 
ent, noted  as  absent  by  resident  medical  officers,  who  were  not  suffi- 
ciently vigilant,  or  were  new  to  their  work.  He  further  states  that  in  the 
year  1804,  when  the  records  were  kept  with  unusual  care,  the  eruption 
was  noted  as  present  in  all  but  55  out  of  2,-4:93  cases,  or  in  97.77  per  cent., 
and  that  some  of  the  cases  in  which  it  was  not  found  were  admitted 
after  the  patient  had  passed  through  the  attack,  so  that  the  probability 
that  the  eruption  had  been  present  and  had  disappeared  is  to  be  re- 
gai'ded. 

All  observers  agree  that  the  eruption  is  absent  in  a  very  small  propor- 
tion of  the  cases,  and  that  it  is  of  diagnostic  importance.  Both  the 
mottling,  or  subcutaneous  rash,  and  the  distinct  measly  eruption,  are 
darker  and  more  distinct  upon  the  dependent  parts  of  the  body.  The 
back  should,  therefore,  always  be  carefully  examined  in  case  of  doubt. 

The  character  of  the  eruption  has  already  been  described  in  the  con- 
sideration of  the  clinical  history  of  this  fever.  The  mottling  and  the  dis- 
tinct rash  usually  exist  together;  but  in  the  lighter  cases,  and  particularly 
in  children,  the  former  mainly  constitutes  the  eruption,  while  in  older 
persons  the  distinct  rash  is  very  prominent.     The  proportion  of   cases  in 


278  THE    CONTINUED    FEVERS. 

Avhicli  the  eruption  is  altogether  absent  is  much  greater  under  the  age  of 
fifteen  than  over  it.  In  children  true  petechi;e  rarely  appear;  but  they 
have  been  observed  at  all  periods  of  life,  from  earliest  infancy  to  extreme 
old  age. 

A  copious  eruption,  deep  in  color  and  early  becoming  livid  or  pete- 
chial, generally  accompanies  the  severe  cases  of  the  disease.  The  extent 
and  distinctness  of  the  eruption,  and  in  particular  its  lividity  and  the 
abundance  of  the  petechias,  have  been  regarded  in  all  times  as  proportion- 
ate to  the  general  severity  of  the  case. 

The  absence  of  the  eruption,  in  the  rare  cases  in  which  it  is  wholly  ab- 
sent, is  not  always  of  itself  of  favorable  import.  Lebert  states  that  in 
his  experience  such  cases  liave  proved  very  serious,  and  in  several  in- 
stances have  terminated  fatally.  On  the  other  hand,  Murchisou  lias  found 
the  cases  without  any  eruption  mostly  mild. 

The  eruption  shows  itself  on  the  fourth  or  fifth  day,  as  a  general  rule; 
i:  may,  however,  appear  aipoii  the  third  day,  or  not  until  the  end  of  the 
first  week  after  the  beginning  of  the  fever.  The  cases  in  which  it  appears 
later  than  the  sixth  dav  are  extremely  rare.  It  is  first  seen  upon  the  sides 
of  the  chest  or  abdomen,  or  in  rarer  cases  upon  the  backs  of  the  hands  or 
the  wi-ists,  and  spreads  rapidly  over  the  trunk  and  extremities,  respecting 
only  the  neck,  face,  the  hairy  scalp,  and  tlie  palms  of  the  hands  and  soles 
of  the  feet;  but  even  these  exceptions  are  not  constant,  and  cases  are  not 
very  rarely  observed,  especially  in  childhood,  in  which  the  distribution 
of  the  typhus-eruption  is  not  less  extensive  than  that  of  measles.  A 
diffuse,  erythematous  blush  is  not  infrequent  during  the  first  day  or  two 
after  the  appearance  of  the  eruption.  If  the  spots  are  faintly  raised 
above  the  surface  of  the  skin,  their  grouping  presents  a  close  resem- 
blance to  measles — a  resemblance  heightened  by  the  conjunctival  injec- 
tion, and  the  nasal  and  pulmonary  catarrh,  which  are  also  at  this  time 
well  developed. 

The  eruption  of  typhus  never  ai:)pears,  as  does  that  of  enteric  fever, 
in  successive  crops.  It  requires  in  most  instances,  apparently  from  its 
very  abundance,  a  variable  time,  often  forty-eight  or  even  sixty  hours, 
for  its  full  development;  but  the  spots  that  appear  upon  the  second  or 
third  day  ai'e  superadded  to  those  first  seen,  and  are  due  to  the  same  cause. 
After  the  rash  is  completely  established,  it  is  permanent,  no  new  spots 
of  the  same  kind  appearing.  Its  average  duration  is  from  eight  to  eleven 
days;  it  disappears,  as  a  rule,  with  the  defervescence.  In  some  cases, 
and  particularly  Avhen  it  has  consisted  only  of  a  faint  mottling,  it  lasts 
but  a  brief  time — from  a  few  hours  to  a  day  or  two — and  wholly  A'anishes 
several  days  before  the  termination  of  the  fever.  Where  the  eruption 
is  very  dark,  and  where  true  petechiae  are  abundant,  the  discoloration  of 
the  skin  ])ersists  for  some  days  into  the  convalescence,  and  only  gradually 
fades. 


TYPHUS    FEVEll.  279 

The  course  of  the  typlius-eruption  is  as  follows:  at  first  the  lesion 
consists  of  a  hyperjemia  of  tlie  cutaneous  capillaries,  which,  bein"-  in 
])art  diffuse,  is  manifested  by  that  mottling  or  marbling  of  the  surface, 
described  as  the  subcuticular  rash;  and  being  in  part  localized,  shows 
itself  in  the  pale,  dirty  pink  or  florid  spots,  faintly  raised  above  the  sur- 
face, disappearing  upon  pressure,  and  variously  grouped,  Avhich  have  al- 
ready been  described  as  the  rubeoloid  or  measly  eruption.  In  the  course 
of  two  or  three  days  these  spots  are  found  to  be  no  longer  elevated;  they 
have  lost  the  brightness  of  their  color,  and,  in  consequence  of  the  transu- 
dation of  blood-coloring  matter  from  the  vessels,  appear  as  i-eddish  brown 
or  rust-colored  stains  in  the  skin,  not  distinctly  marginate,  but  fadino-  ob- 
scurely into  the  tint  of  the  surrounding  surface.  The  hyperjemia  has  now 
given  place  to  pigmentation,  which  cannot,  however,  be  called  petechial. 
The  spots  no  longer  disappear,  although  they  grow  less  distinct  under 
pressure.  This  change  does  not  usually  affect  all  the  spots.  Manv  of 
them,  under  ordinary  circumstances,  gradually  disappear  about  the  middle 
of  the  second  week  of  the  fever,  or  at  the  approach  of  the  crisis.  In  tlie 
second  week  a  minute  extravasation  of  blood  appears  at  the  centre  of 
some  of  the  pigmented  spots,  and  in  certain  cases  petechiie  appear,  not 
as  a  step  in  the  evolution  of  the  typhus-eruption,  but  as  such  from  the 
beginning.  The  blood-stainings  in  the  site  of  the  spots,  and  the  true 
})etechi8e,  are  alike  uninfluenced  by  pressure.  The  duration  of  the  vari- 
ous stages  of  the  eruption  is  by  no  means  constant.  In  truth,  it  may 
come  to  an  end  without  passing  into  the  rusty  color;  still  less  before  the 
appearance  of  petechias.  In  some  cases  the  eruption  is  rusty,  or  livid 
and  petechial,  from  a  very  early  stage,  or,  in   fact,  from  its  beginnino-. 

If  death  occur  while  the  eruption  is  pinkish  or  florid  and  disappears 
on  pressure,  no  trace  of  it  is  seen  in  the  dead  body;  but  if  it  has  become 
rusty,  or  if  petechia^  have  developed,  the  eruption  is  persistent,  and  upon 
examination  of  sections  of  the  skin  it  is  found  to  be  stained  by  the  color- 
ing-matter of  the  blood. 

The  subcuticular  mottling  usually  disapDears  after  a  few  days,  while 
the  spots  grow  darker  and  more  distinct. 

Hence,  as  Murchison  has  pointed  out,  the  eruption  of  typhus  is  pale 
and  blended  in  the  early  stages,  darker  and  more  spotted  in  the  later 
periods. 

True  petechia?  are  neither  essential  nor  peculiar  to  typhus.  In  many 
cases  they  do  not  occur  at  all — in  few  before  the  last  stages. 

The  erythematous  blush  which  attends  the  outbreak  of  the  eruption 
usually  quickly  subsides.  In  the  later  periods  of  grave  cases  the.  skin 
grows  dusky  or  livid,  especially  in  the  dependent  portions  of  the  body. 

Vibices  and  larger  transudations  of  blood  beneath  the  skin  (ecchj/mo- 
ses)  also  occur  in  grave  cases,  and  especially  where  scurvy  exists  as  a  com- 
plication, as  it  did  in  the  war  of  the  Crimea. 


280  TllK    CONTINUKU    FKVKKS. 

-Murchi.son  uunilions  "'  taelies  bhiudtres '"'  as  occasionally  occurring. 

Snda)ni)ia  are  occasionally  met  witli.  They  are  more  common  before 
than  after  the  fortieth  year  of  age,  and  may  occur  eitlicr  Avith  or  Avithout 
marked  sweating. 

Desquamation  follows  the  disappearance  of  the  eruption  in  a  limited 
number  of  cases.  It  is  fine  and  bran-like,  and  proceeds  from  above  down- 
wanl,  but  may  become  coarse  or  membranous  on  the  hands  and  feet. 
The  nails  show  a  white  band  and  a  furrow  as  the  result  of  the  disturb- 
ance of  nutrition  Avliich  attends  the  fever.  There  is  in  most  instances 
more  or  less  falling'  of  the  liair  during  the  convalescence. 

Tl'tlcaria  occasionally  makes  its  appearance  in  young  persons  about 
the  time  of  the  crisis,  or  early  in  the  convalescence. 

JTerpes  occurs  exceptionally.  It  may  precede  the  orujition  and  give 
rise  to  brief  confusion  of  diagnosis.  It  also  occasionally  appears  towani 
the  termination  of  the  disease. 

Erysipelas  has  occurred  with  frequency  in  the  wards  of  certain  hos- 
pitals, and  is  due  to  hospital  influence  rather  than  to  the  processes  of  ty- 
phus. It  is  a  serious  complication,  but  not  necessarily  fatal.  It  appears 
usuallv  upon  the  approach  of  or  during  convalescence,  and  is  usually  con- 
fined to  the  face  and  head. 

These  eruptions  are  accidental. 

77ie  general  appearance  of  the  patient  ill  of  t^-phus  fever  is  peculiar. 
It  is  often  of  Itself  so  striking  as  to  Indicate,  even  to  a  person  of  limited 
experience,  the  nature  of  the  disease,  and  in  cases  of  doubt  it  Is  of  diag- 
nostic value.  The  expression  of  the  countenance,  the  appearance  of  the 
skin,  the  attitude,  considered  together,  constitute  what  may  be  called  the 
])hysIognomy  of  the  disease.  From  the  first  the  face  Is  the  index  of  the 
grave  derangement  of  the  functions  of  the  nervous  system  that  are  so 
]iroininent.  The  look  is  dull  and  heavy;  as  Da  Costa  has  well  said, 
it  is  '"coarser"  than  in  health.  It  is  also  most  weary.  As  the  case  pro- 
gresses the  expression  becomes  blank  and  stupid,  the  eyes  are  half- 
closed,  or  widely  open  and  staring  at  nothing,  and  the  lips  relaxed, 
l^arted,  the  lines  indicating  thought  and  emotion  blurred  or  altogether 
blotted  out.  The  facial  expression  varies  with  the  form  of  the  delirium. 
In  typhomania  It  Is  feeble,  fatuous,  or  silly;  In  the  trembling,  which  so 
closely  resembles  the  delirium  tremens  of  alcoholism.  It  Is  eager,  rest- 
less, suspicious,  and  when  the  delirium  Is  active  or  acute,  the  expres- 
sion is  often  bold  and  defiant.  If  it  Is  at  all  anxious,  it  betrays  the 
terror  or  anxiety  due  to  some  fixed,  distressing-  Idea  with  which  the 
delirious  brain  busies  Itself,  not  the  anxiety  of  suffering  or  suspense  met 
with  In  many  acute  diseases,  for  the  pains  of  typhus  are  not  commonly 
acute,  and  it  Is  rare  for  the  patient  to  manifest  concern  as  to  the  Issue 
of  his  slcktiess. 

A  uniform  general  flushing  of  the  face  or  cheeks  Is  generally  j)resent. 


'IVPHUS    FKVEK.  281 

It  may  be  deepest  over  tlie  cheek-bones,  but  it  is  never  circumscribed.  It 
is  not  pink  or  florid,  but  of  a  dull,  dusky-red  color,  or  it  may  be  of  an 
earthy  or  leaden  hue.  In  the  advanced  stage  of  grave  cases  the  face  is 
often  livid,  pai'ticularly  about  the  mouth  and  nostrils.  The  eyes  are  suf- 
fused and  the  conjunctivae  injected  ;  sordes  collect  upon  the  lips  and 
teeth. 

The  patient  lies  most  veearily  upon  his  back.  In  the  graver  cases  he 
is  unable  to  move  in  bed,  or  to  help  himself.  He  lies  with  his  hands 
crossed  upon  his  abdomen  or  extended  at  his  sides,  unconscious  of  or  in- 
different to  what  ffoes  on  about  him. 


SYMPTOMS    REFERABLE   TO    THE   RESPIRATORY    SYSTEM. 

The  respiratory  nwveineNts  are  moderately  accelerated  during  the  first 
week,  ranging  from  twenty  to  twenty-four  per  minute  in  uncomplicated 
cases.  With  the  advent  of  delirium  and  the  increased  frequency  of  the 
pulse  which  attends  the  developing  prostration,  the  respiration  becomes 
more  hurried  and  shallower.  In  grave  cases,  in  which  the  disturbance  of 
the  nervous  system  is  profound,  the  respiration  is  sometimes  abnormally 
slow.  It  is  more  commonly  hurried,  aiid  may  without  pulmonary  com- 
plication be  irregular,  sighing,  or  jerky. 

Affections  of  the  lungs,  as  in  enteric  fever,  are  very  common.  Of 
these,  the  most  are  to  be  regarded  as  complications,  and  will  be  consid- 
ered under  that  heading.  But  the  bronchitis,  which  is  usually  present  in 
the  first  week,  appearing  coincidently  with  the  nasal  and  conjunctival 
catarrh,  seems  worthy  to  be  regarded  as  a  symptom.  It  is  at  first  at- 
tended with  but  slight  cough  ;  little  expectoration,  or  none  at  all  ;  no 
difficulty  and  but  little  quickening  of  the  movements  of  respiration,  and 
there  are  detected  upon  auscultation  a  few  scattered,  subcrepitant,  sono- 
rous or  sibilant  rales.  During  the  second  week  the  bronchitis  may  become 
diffuse,  and  extend  to  the  capillary  tubes.  This  it  may  do  in  an  insid- 
ious manner,  without  much  cough  or  other  danger-symptoms  except 
quickening  of  the  breathing.  In  other  cases  the  pulmonary  symj^toms 
become  grave,  or  they  may  even  predominate  so  that  the  case  may  assume 
the  form  that  has  been  described  as  bronchial  typhus.  Physical  explora- 
tion reveals  subcrepitant  rules  in  all  parts  of  the  chest,  localized  bronchial 
breathing  with  dulness,  areas  of  very  faint  respiratory  sounds,  or  exten- 
sive hypostatic  congestions,  or  the  signs  of  lobar  pneumonia. 

SYMPTOMS   REFERABLE    TO    THE   DIGESTHE    SYSTEM. 

The  affections  of  the  digestive  tract  consist  chiefly  of  perverted  func- 
tions and  of  catarrlial  conditions  of  the  mucous  membrane  of  the  mouth, 
pharynx,  stomach,  and  intestines. 


282  THE  CONTINUED  FEVEKS. 

Tlic  tongue  is  at  first  covered  with  a  thick  wliitisli  or  yellowish-white 
fur.  It  may  remain  thus  furred  and  moist  throughout  the  attack  in  mild 
cases;  but,  as  a  rule,  it  becomes,  at  the  end  of  the  first  or  the  beginning 
of  the  second  week,  dry  and  brown  or  brownish  along  its  middle.  In 
severe  cases  it  is  very  dry,  often  retracted  into  a  globular  mass,  and  is 
coated  with  a  dry,  dark  crust,  which  sometimes  cracks  at  several  places. 
In  severe  cases  attended  with  j^rofound  asthenia  the  tongue  is  sometimes 
moist  throughout.  The  tip  and  edges  are  usually  pale.  The  deep  fis- 
sures so  often  met  with  in  enteric  fever,  and  occasionally  in  relapsing 
fever,  are  rare  in  typhus.  The  tongue  is  protruded  tremulously,  espe- 
cially in  the  second  week  of  the  disease.  It  is  sometimes  protruded  with 
difficulty,  or  not  at  all;  apparently  in  some  cases  from  sheer  weakness, 
in  others  from  dulness  of  intellect,  and  yet  in  others  on  account  of  its 
dry  and  firmly  contracted  state, 

Sordes  begin  to  collect  upon  the  gums  and  teeth,  and  even  upon 
the  lips,  about  the  beginning  of  the  second  week.  The  gums  also  bleed 
at  times,  but  this  phenomenon  is  usually  associated  with  a  scorbutic 
tendency. 

Loss  of  a2)2>Gtite  is  complete  throughout  the  attack.  A  desire  for  food 
is  very  often  expressed  immediately  upon  awaking  from  the  sleep  that 
marks  the  crisis,  and  it  is  not  a  very  unusual  circumstance  for  patients  to 
ask  for  food  shortly  before  the  crisis,  before  any  indication  of  improve- 
ment as  regards  the  general  symptoms  is  apparent. 

Thirst  is  a  constant  symptom.  It  varies  greatly  in  urgency,  and  is 
excessive  in  about  one-fourth  the  cases.  It  is  most  prominent  during  the 
first  week,  and  diminishes  or  altogether  ceases  upon  the  advent  of  the 
graver  nervous  symptoms  that  set  in  with  the  second  Aveek. 

Difficulty  in  sicallowing  occurs  in  a  small  proportion  of  the  severer 
cases.  It  first  appears  in  the  later  periods  of  the  disease,  and  may  be  due 
to  the  extreme  dryness  of  the  mouth  and  throat,  or  to  spasm  or  paralv- 
sis  of  the  muscles  concerned  in  deglutition. 

y^iiusea  and  vomiting  are  not  common  in  typhus.  Vomiting  has  been 
noted  in  from  six  to  ten  per  cent,  of  the  cases  in  some  epidemics  in  which 
it  was  made  the  subject  of  special  investigation.  It  is  in  most  instances 
an  early  symptom,  but  may  recur  for  a  day  or  two  preceding  the  crisis, 
and  in  some  cases  is  confined  to  the  period  of  convalescence.  In  dys- 
peptic persons  it  may  continue  throughout  the  attack.  The  matters 
ejected  usually  consist  of  thin,  gastric  mucus  tinged  with  bile. 

Vomiting  may  be  the  forerunner  of  the  symptoms  of  uraemic  toxici- 
tion,  such  as  general  convulsions  and  coma.  Occurring  toward  the  end 
of  the  first  or  th^  beginning  of  the  second  week,  it  thus  becomes  a  symp- 
tom of  the  gravest  significance,  and  should  direct  the  attention  of  the 
physician  to  the  closest  scrutiny  of  the  amount  and  character  of  the 
urine,  and  particularly  to  the  absence  or  presence  of  albumen,  if  these 


TYPHUS    FEVEK.  283 

matters  have  not  already  been  made,  as  they  invariably  should  be,  the 
subject  of  routine  examination. 

Tympany  is  rare  in  typhus.  In  those  cases  in  which  it  occurs  it  is  a 
later  symptom,  and  is  associated  with  grave  depression  of  the  nervous 
system.  It  may  so  distend  the  belly  and  interfere  with  the  descent  of 
the  diaphragm  as  to  seriously  embarrass  respiration. 

Abdominal ixAin  arid  tenderness  2.\(i  not  common.  Slight  colicky  pains 
may  occur  during  tlie  first  week,  and  there  is  usually  a  little  obscure 
tenderness  in  the  hepatic  region.  Pain  or  deep  tenderness  localized  in 
the  area  corresponding  to  the  ilio-cajcal  region  of  the  gut  does  not  occur. 

Hie  liver  is  slightly  enlarged  in  rather  less  than  one-third  of  the  cases. 

Enlargement  of  the  spleen  is  discovered  in  the  greater  number  of  cases 
of  typhus  by  physical  examination  during  life,  and  this  organ  is  found  to 
be  enlarged  and  softened  in  about  three-fourths  the  cases  examined  after 
death.  The  enlargement  is  acute,  and  may  be  made  out  by  tlie  fifth  day. 
It  is  less  common  than  in  enteric  fever,  and  does  not  attain  the  limits 
common  in  relapsing  and  malarious  fevers. 

Co)istipatio}i  is  very  common  in  typhus.  In  many  cases,  however, 
the  bowels  are  moved  regularly,  and  exceptionally  there  is  diarrhoea. 
The  state  of  the  bowels  varies  in  diiferent  epidemics.  Lebert  mentions 
that  diarrJicea  was  frequent  in  tiie  typhus  epidemics  observed  by  him  at 
Breslau,  and  ])a  Costa  and  other  observers  of  typhus  in  the  United  States 
luive  noted  it  as  a  frequent  symptom.  Spontaneous  diurrlicBa  is  not  com- 
mon in  the  lighter  cases.  Of  31  cases  noted  by  Da  Costa  at  Philadelphia, 
this  symptom  was  present  to  a  marked  degree  in  13,  or  41.9  per  cent. 
Murcliison,  on  the  other  hand,  informs  us  that,  of  1,782  cases  collected 
from  various  sources,  diarrhoea  occurred  in  only  184,  or  in  10.32  per  cent., 
while  in  059  of  1,739  cases,  or  55.14  per  cent.,  there  was  obstinate  con- 
stipation; and  of  14,589  cases  admitted  to  the  London  Fever  Hospital 
during  nine  years  (1803-70),  only  734,  or  5  per  cent.,  suffered  from  diar- 
rhoea. Of  the  734  patients  in  whom  diarrhoea  occurred,  178,  or  24.25 
})er  cent.,  died,  while  the  death-rate  of  patients  in  whom  diarrhoea  did  not 
occur  was  only  18.14  per  cent.  Diarrhoea  may  be  present  in  the  early 
days  of  the  attack,  or  may  occur  at  any  time  during  its  course,  either 
spontaneously  or  as  a  result  of  purgative  medicines.  It  is  also  observed 
at  the  crisis.  It  is  usually  mild,  but  may  in  rare  cases  be  very  trouble- 
some, or  even  so  excessive  as  to  endanger  the  life  of  the  patient  by  the 
increased  prostration  to  which  it  gives  rise.  Involuntary  discharges  oc- 
cur in  cases  of  the  most  serious  kind,  and  commonly  upon  the  approach 
of  death. 

The  stools,  when  there  is  diarrlioea,  are  usually  of  a  dark,  greenish  brown 
color,  and  of  a  less  fluid  consistency  than  in  enteric  fever;  in  some  cases 
they  are  of  a  light  color  and  watery.  In  Da  Costa's  cases  the  stools  were 
small,  thin,  and  feculent,  often  offensive,  and  of  a  yellowish  color.     They 


284  THE  CONTINUED  FEVERS. 

are  not  coininonly  attended  by  pain   or   tenderness,  altliou«r}i    iu  rare   in- 
stances the  movements  are  preceded  by  colicky  pains. 


Complications  axd  Sequkls. 

The  complications  of  typhus  are  numerous.  They  vary  in  different 
epidemics,  but  sometimes  appear  to  be  determined  by  individual  peculi- 
arities, different  members  of  the  sam>e  family  presenting,  when  attacked 
by  the  disease,  the  same  complications,  such  as  convulsions,  iialsies,  gan- 
grene, and  the  like.  The  fatal  termination  is  not  infrequently  due  to 
some  complication;  and  the  occurrence  of  a  complication  may  postpone 
the  critical  defervescence  or  arrest  it  altogether,  and  thus  prolong  the 
attack  to  an  unusual  length,  and  cause  it  to  end,  in  cases  ultimately  fa- 
vorable, by  a  gradual  defervescence  (lysis). 

The  convalescence  may  be  interrupted  and  greatly  prolonged  by  the 
development  of  sequels. 

Affections  of  the  respiratory  tract  are  common  and  serious  in  typhus. 

A^cute  laryngitis,  leading  speedily  to  oedema  of  the  glottis,  is  of  occa- 
sional occurrence.  This  may  occur  of  itself  as  a  secondary  affection,  or  it 
may  be  led  in  by  ulceration  of  the  larynx,  by  a  post-pharyiigeal  abscess, 
by  enlargement  and  suppviration  of  the  parotid  or  submaxillary  glands, 
or  it  may  occur  in  consequence  of  erysipelas.  Its  advent,  either  with  or 
without  preceding  inflammatory  processes  in  contiguous  structures,  is  in- 
sidious. Slight  huskiness  may  be  quickly  followed,  after  a  brief  period, 
by  laryngeal  breathing  and  the  signs  of  impending  asphyxia,  rendering 
prompt  larj'ngotomy  or  tracheotomy  necessary  to  save  life. 

The  laryngitis  is  sometimes  croupous,  and  diphtheria  of  the  larynx 
and  pharynx  occur. 

Laryngeal  ulceration  is  less  common  than  in  enteric  fever. 

The  obscure  onset  of  the  pulmonary  complications  of  typhus  has  al- 
ready been  alluded  to.  It  is  of  the  utmost  importance  that  systematic 
physical  exploration  of  the  chest  be  made  from  day  to  day.  The  gravest 
chest-complications  may  be  developed  with  but  little  cough,  little  or  no 
expectoration,  and  no  complaint  of  pain  whatever.  The  debility  of  the 
patient  and  his  blunted  perception  serve  to  mask  the  special  symptoms 
of  lung-trouble.  Hurried  respiration  and  increased  duskiness  of  the  face 
are  the  danger-signals. 

Bronchitis  has  already  been  spoken  of.  It  is,  in  fact,  a  symptom 
rather  than  a  complication.  The  great  danger  lies  in  its  tendency  to 
become  diffuse  and  to  extend  into  the  finer  tubes,  and  thus,  leading  to 
atelectasis  and  secondary  lobular  pneumonia,  to  destroy  the  patient  by 
cutting  off  extensive  areas  of  breathing  surface. 

True  lobar  pneumonia  is  infrequent  in  typhus.  It  is  manifested  by 
the  usual  signs,  dulness — crepitus,  bronchial  respiration,  and  rusty  sputa. 


TYPHUS    FEVER.  285 

Gangrene  of  the  Ikhc/  also  occasionally  occurs;  it  is  manifested  by 
the  peculiar  and  horrible  fcetor,  supervening'  upon  the  signs  of  acute 
inflammatory  processes  affecting  the  lungs,  the  altered  look  of  the  pa- 
tient, and  a  simultaneous  agg'ravation  of  all  the  symptoms.  It  is  usually 
fatal. 

Pleural  ej^'i(siu?is,  both  serous  and  purulent,  occur  in  rare  instances. 
Unless  the  chest  be  systematically  explored  they  are  apt  to  be  overlooked, 
as  they  come  on  insidiously,  without  pain,  and  do  not  greatly  embarrass 
the  respiration  until  they  have  attained  considerable  volume. 

Phthisis  is  sometimes  lighted  up  during  the  attack  of  typhus  or  in 
the  convalescence.  The  catarrhal  pneumonia  persists,  and  rapid  emacia- 
tion, night-sweats,  and  muco-purulent  sj^uta  occur. 

Jilood-sjyitting  is  a  very  rare  occurrence  in  typhus  fever.  Murchison 
points  out  the  fact  that  it  may  occur  in  consequence  of  the  pulmonary 
hyperfemia  in  a  previously  diseased  lung,  or  by  reason  of  the  existence 
of  the  hemorrhagic  diathesis. 

Other  hemorrhages  are  not  uncommon  in  grave  cases — not  alone  when, 
as  so  often  has  happened  in  camps  and  armies  and  in  times  of  protracted 
scarcity  of  food,  scurvy  complicates  the  disease,  but  also  when  no  such 
predisposing  cause  is  present.  Bleeding  from  the  nose,  the  gums,  the 
bowel,  the  urinary  passages,  and  the  vagina,  as  well  as  the  spitting  and 
vomiting  of  blood,  have  been  observed.  Slight  wounds  and  superficial  ex- 
coriations may  give  rise  to  serious  or  even  fatal  hemorrhage.  These 
events  are  unusual.  But,  in  many  epidemics,  large  subcutaneous  extrava- 
sations of  blood  are  common,  and  after  death  similar  effusions  are  found 
beneath  the  mucous  and  serous  membranes,  in  the  intermuscular  planes, 
and  within  the  substance  of  the  muscles. 

Polls  occasionally  break  out  in  numbers  during  the  convalescence. 
They  constitvite  a  troublesome  sequel. 

Among  the  rarer  complications  of  typhus  is  lyymmia  with  inirulent 
deposit  in  the  joints.  It  begins  with  severe  chills,  followed  by  great  pros- 
tration, rapid  and  feeble  pulse,  and  acute  swelling  of  the  joints  with  ten- 
derness and  redness.  There  is  commonly  jaundice  and  sweating.  The 
smaller  joints  also,  are  often  implicated.  After  death  the  joints  are  found 
to  contain  pus,  but  abscesses  in  the  internal  organs  are  rare.  This  com- 
plication usually  apjDears  at  the  time  of  the  crisis,  or  early  in  the  conva- 
lescence. 

Phlegmasia  dolens  was  noted  as  of  common  occurrence  in  the  conva- 
lescence in  those  epidemics  in  which  bleeding  entered  largely  into  the 
treatment.      This  complication  has  been  very  rare  in  recent  epidemics. 

When  erysipelas  occurs,  it  usually  comes  on  late  in  the  fever  or  early  in 
the  convalescence.  Much  more  rarely  it  occurs  shortly  after  the  begin- 
ning of  the  disease.  It  commonly  commences  about  the  root  of  the  nose 
or  the   lobe   of   one  ear,  and  spreads  over  the  face  and  scalp,  sometimes 


,286  THE    CUJMTINUKD    FEVERS. 

leading  to  the  formation  of  abscesses  of  the  eyelids  and  of  the  integuments 
elsewhere.  The  pharynx  and  larynx  are  very  often  implicated  in  the 
erysipelatous  process,  and  cedenia  of  the  glottis  sometimes  results.  Ery- 
sipelas occurs  less  frequently  in  other  parts  of  the  body.  Many  cases 
of  er^'sipelas  arising  at  the  same  time,  where  typhus  fever  patients  are 
crowded  together  in  a  hospital  ward,  are  to  be  attributed  rather  to  bad 
hygienic  influences  than  to  the  typhus  processes. 

iJiffiise  mjiamrnatlou  of  the  subcutaneous  tissues,  resulting  in  purulent 
infiltration,  occasionally  occurs,  most  commonly  in  the  lower  extremities. 
It  is  attended  by  the  symptoms  of  serious  constitutional  disturbance  and 
pain  in  the  affected  part. 

Enlargement  and  suppuration  of  the  parotid  gland  occur  early  in 
many  epidemics.  Sometimes,  however,  they  are  met  with  about  the  time 
of  the  crisis,  and  again  they  may  not  be  developed  until  convalescence. 
They  occur  at  all  periods  of  life,  but  are  proportionately  more  common 
after  the  thirtieth  year.  The  tumefaction  forms  rapidly  and  suppuration 
speedily  follows.  Resolution,  however,  may  occur  without  the  formation 
of  matter.  The  connective  tissue  overlying  the  glands  is  largely  involved 
in  the  suppurative  process.  The  parotitis  is  often  associated  with  facial 
erysipelas  or  with  extensive  inflammatory  cedema  of  the  neck.  This  is  a 
very  dangerous  complication.  These  inflammatory  swellings  occur  also 
in  the  submaxillary  glands,  in  the  mammae,  the  glands  of  the  axilla  and 
groin,  and  less  frequently  in  the  extremities.  Their  number  is  sometimes 
limited  to  one  or  two;  sometimes  they  are  numerous.  They  occasionally 
result  in  extensive  gangrenous  ulcers.  In  many  epidemics  they  are  absent. 
Parotid  buboes  and  other  inflammatory  swellings  occurring  in  typhus,  sug- 
gest a  relationship  between  this  disease  and  the  true  plague.  Murchison 
suggests  that  typhus  is  probably  the  plague  of  modern  times. 

JBed-sores  are  not  very  frequent  in  uncomplicated  typhus.  They  are 
apt,  however,  to  occur  in  cases  protracted  by  other  complications.  They 
appear  in  those  parts  of  the  body  subjected  to  pressure,  the  most  common 
situation  being  over  the  sacrum.  They  also  occur  in  the  heels,  upon  the 
back  of  the  head,  at  the  trochanters,  and  over  the  vertebra  prominens. 
They  protract  the  duration  of  the  illness,  and  may  bring  about  a  fatal 
termination  of  the  case  by  exhaustion  or  b}''  septicaemia. 

Parts  not  subjected  to  pressure  may  become  gangrenous  in  conse- 
quence of  arterial  thrombosis.  The  death  of  the  tissues  is  usually  preceded 
by  darting  pains  and  the  signs  of  arrested  circulation  in  the  part,  namely, 
numbness,  coldness,  and  livid  discoloration.  The  feet  and  ankles  are  apt 
to  be  involved,  less  frequently  the  nose,  the  penis  and  scrotum,  and  the 
external  genitalia  in  the  female. 

In  severe  epidemics  many  observers  have  noted  the  tendency  of 
wounds  and  ulcerated  surfaces  to  become  gangrenous  in  typhus-patients 
and  even  in  those  not  suffering  from  the  disease.     Under  such  circum- 


TYPHUS    FEVER.  287 

Stances  gangrene  has  resulted  from  the  application  of  blistei'S  and  sina- 
pisms. 

Perforating  ulceration  of  both  corneje  occasionally  occurs,  in  conse- 
quence of  the  exposure  of  the  globe  from  the  eyelids  being  kept  con- 
stantly open. 

JVojna  or  cancrum  oris  occurs  in  some  epidemics.  It  is  fortunately 
a  very  rare  complication,  but  is  fatal  in  most  instances.  It  is  more  fre- 
quent in  children  than  in  adults. 

JVeci'osis  is  a  rare  result  of  typhus,  as  of  other  severe  fevers.  Murchi- 
son  saw  in  one  instance  extensive  necrosis  of  the  fibula  follow  an  attack 
of  typhus.     It  is  probably  secondary  to  arterial  thrombosis. 

Pericarditis  and  endocarditis  are  extremely  rare. 

In  rare  instances  mental  feebleness  follows  the  attack;  but,  as  a  rule, 
the  intellectual  faculties  are  restored  shortly  after  the  crisis.  Maniacal 
attacks  sometimes  occur  during  the  convalescence.  They  are  usually 
transient. 

Palsy  may  occur  as  a  sequel  of  typhus  fever.  It  may  involve  both 
lower  extremities  or  one-half  the  body.  Numerous  examples  of  hemi- 
plegia are  recorded,  and  there  are  not  a  few  cases  of  right  hemiplegia 
with  aphasia  to  be  found  in  the  literature  of  the  subject.  In  other  cases 
the  palsy  is  restricted  to  individual  muscles  or  groups  of  muscles.  In  very 
rare  instances  paralysis  of  one  side  of  the  face  has  been  observed. 

The  paralysis  following  typhus  usually  terminates,  in  the  course  of 
some  days  or  weeks,  in  recovery.      It  may,  however,  be  persistent. 

The  deafness  which  so  frequently  attends  the  fever  usually  passes 
away  in  the  early  days  of  convalescence.  Inflammation  of  the  external 
auditory  meatus,  or  of  the  middle  ear,  may  give  rise  to  permanent  impair- 
ment of  hearing  upon  one  or  both  sides,  and  suppurative  inflammation  of 
the  ear  may  be  remotely  followed  by  secondary  inflammation  of  the  men- 
inges, as  in  scarlet  fever. 

Transient  dimness  of  vision  is  occasionally  noticed  after  severe  at- 
tacks (Murchison). 

It  remains  to  notice  some  of  the  comjjlications  due  to  derangements 
of  the  digestive  tract.  Murchison  saw  one  case  of  acute  glossitis  in  his 
great  experience.  The  patient  recovered  after  free  incision  of  the  tongue. 
The  occurrence  of  diarrhoea  has  already  been  spoken  of.      (See  p.  383.) 

Dysentery  has  prevailed  in  some  epidemics,  side  by  side  with  typhus, 
and  especially  in  many  outbreaks  in  camps  and  besieged  cities,  and  has, 
under  such  circumstances,  become  a  frequent  complication. 

Jaundice,  a  frequent  symptom  in  relapsing  fever,  is  very  rare  in  ty- 
phus. When  it  arises,  it  is  due  either  to  congestion  of  the  liver,  or  to  gas- 
tro-duodenal  catarrh  occurring  as  complications;  or  it  may  be  one  of  the 
group  of  symptoms  belonging  to  pyaemia;  or,  finally,  it  may  appear  about 
the  time  of  the  manifestation  of  the  typhus-rash,  as   one  of  the  expres- 


288  THE  CONTINUED  FEVERS. 

sions  of  the  overwhelming-  action  of  the  poison  upon  the  blood.  It  is 
then  to  be  regarded  as  an  ominous  indication. 

If  ■)nenstr nation  occur  during  the  course  of  typhus,  it  may  be  profuse 
and  even  endanger  life.  Murchison  states  that  he  knew  of  one  case  in 
which  death  was  due  to  flooding. 

Pre<jiia^icy  affords  no  exemption  from  the  attack  of  typhus.  Preg- 
nant women,  even  in  the  more  advanced  stages,  may  suffer  from  typhus 
without  miscarriage;  and  when  this  accident  does  occur,  it  is  not  neces- 
sarily fatal  to  either  the  mother  or  child.  During  nine  years  (18G2-70) 
107  typhus-patients  in  the  London  Fever  Hospital  were  known  to  be  preg- 
nant. Of  this  number  49  aborted  from  the  tenth  to  the  fourteenth  day 
of  the  attack;  of  those  who  aborted  9  died.  The  remaining  98  recovered 
(Murchison). 

In  respect  of  the  tendency  to  miscarriage  and  the  danger  to  the  life 
of  the  child,  typhus  is  in  strong  contrast  Avith  relapsing  fever. 

Varieties. 

The  general  characters  of  typhus  present  but  little  variation.  The 
picture  seen  at  the  bedside  has  in  the  main  the  same  general  outlines  and 
coloring  in  all  epidemics.  Variations  in  the  groupings  of  the  symptoms, 
and  lightening  of  the  tints  or  deepening  of  the  shadows  in  particular 
cases,  are  to  be  attributed  to  differences  in  the  constitution  and  habits  of 
the  patients,  to  differences  in  the  circumstances  under  which  epidemics 
arise,  and,  above  all,  to  the  complications  which  are  so  numerous,  so  com- 
mon, and  frequently  so  important  in  determining  an  unfavorable  ending. 
The  varieties  of  typhus  that  have  been  described  by  various  authors,  who 
have  depended  upon  the  prominence  of  certain  symptoms  or  groups  of 
symptoms  as  a  principle  of  division,  is  very  great.  Among  them  may 
be  mentioned  inflammatory  typhus,  nervous  or  ataxic  typhus,  adynamic 
typhus,  ataxo-adynamic  typhus,  catarrhal,  scorbutic,  purpuric,  and  dysen- 
teric typhus,  and  a  further  exercise  of  ingenuity  could  almost  indefi- 
nitely increase  the  list.  A  more  useful  distribution  of  the  cases  into 
varieties  is  that  based  upon  the  course  and  development  of  the  attack 
considered  in  its  completed  clinical  history.  The  cases,  thus  regarded, 
readily  arrange  themselves  into  the  following  five  groups: 

1.  Common  Typhus. 

2.  Fulminant  Typhus. 

3.  Walking  Typhus. 

4.  Mild  Typhus. 

5.  Abortive  Typhus. 

1.  Tlie  comtnon  form  has  already  been  sufficiently  indicated  in  the 
foregoing  sketch  of  the  clinical  history  of  the  disease,  of  whicli  it  forms 
the  basis. 


TYPHUS    FEVER.  289 

2.  The  fulminant  form  (typhus  siderans)  is  characterized  by  the 
furious  onset  of  the  attack,  the  intensity  of  all  the  symptoms,  the  ex- 
treme to  which  the  temperature  abruptly  rises,  the  early  appearance  of 
grave  cerebral  symptoms,  and  finally  by  the  rapidity  with  which  death  oc- 
curs, this  event  taking  place  within  the  first  three  or  four  days  of  the  at- 
tack, or  even  in  a  few  hours  from  its  beginning.     This  form  is  rare. 

3.  'Walhing  typhus  {typhus  ambulatorius)  begins  insidiously  or  in  an 
intermittent  manner,  so  that  the  patient  is  not  compelled  to  keep  his  bed 
at  first,  or  rises  and  goes  about  after  an  initial  paroxysm.  The  case, 
apparently  benign  at  first,  after  a  time  assumes  the  gravity  characteristic 
of  typhus,  the  patient  suddenly  falling  into  a  state  of  extreme  prostra- 
tion or  even  dangerous  collapse,  or  becoming  delirious  and  manifesting  a 
suicidal  tendency. 

4.  Mild  typhus  {typhus  levisshnus)  is  a  form  unattended  by  severe 
symptoms  of  any  sort.  The  nervous  phenomena  seldom  exceed  headache 
and  mild  delirium  limited  to  the  night.  The  temperature  scarcely  rises 
above  39°  C.  (103.2°  F.).  The  eruption  is  little  marked,  or  absent  al- 
together. The  defervescence  occurs  commonly  on  the  seventh  day,  and 
is  usually  completed  in  the  course  of  the  eighth  day;  it  is  often  attended 
by  herpes.  This  form,  which  is  to  be  distinguished  from  abortive  typhus, 
occurs  more  or  less  frequently  in  all  epidemics.  It  also  occurs  at  times 
and  places  where  typhus  is  endemic  rather  than  epidemic,  and,  in  the  ab- 
sence of  the  eruption,  is  apt  to  be  confounded  with  simple  continued 
fever  or  febricula.  It  is  apt  to  occur  chiefly  among  young  persons,  and 
among  individuals,  who,  although  exposed  to  the  contagion  of  typhus, 
live  under  favorable  hygienic  conditions.  Closely  allied  to  this  form  is 
the  condition  described  by  Jacquot  as  typhisation  d  petite  dose.  This 
condition  is  attended  by  malaise,  slight  fever,  loss  of  appetite,  a  sense  of 
bodily  and  mental  fatigue,  broken  rest  and  some  mental  confusion,  but 
does  not  pass  into  actual  typhus. 

5.  Abortive  typhus  {tyj?hus  dbortivus).  This  form  is  only  to  be 
recognized  by  its  occurrence  during  the  epidemic  prevalence  of  typhus. 
It  begins  abruptly  with  headache,  epigastric  distress,  a  chill  or  chilliness, 
followed  by  decided  fever.  Pains  in  the  back  and  limbs  also  occur. 
There  is  mental  dulness,  a  foul  tongue,  constipation.  The  attack  pre- 
sents, in  short,  all  the  symptoms  characterizing  the  onset  of  the  prevailing 
epidemic  disease.  At  the  end  of  the  second,  third,  or  fourth  day,  however, 
there  is  a  critical  defervescence  accompanied  by  sweating,  diarrhoea,  or,  in 
some  instances  by  vomiting.     Convalescence  then  occurs. 

19 


290  THE  CONTINUED  FEVERS. 


Prognosis  and  Mortality. 


A  knowledge  of  the  duration  of  the  disease  is  important  with  refer- 
ence to  the  prognosis.  The  mean  duration  of  typhus  fever  is  about 
fourteen  days;  mild  cases  may  end  in  permanent  improvement  at  the  close 
of  the  first  or  beginning  of  the  second  week.  The  duration  of  average 
cases  is  from  thirteen  to  fifteen  days.  Uncomplicated  cases  rarely  exceed 
twenty  days.  If  the  defervescence  be  postponed  to  the  end  of  the  third 
•week,  it  is  in  consequence  of  some  local  complication.  The  mean  duration 
of  500  cases  that  terminated  in  recovery  was,  according  to  Murchison, 
13.43  days,  while  the  mean  duration  of  100  fatal  cases  was  14.6  days,  but 
in  all  of  the  fatal  cases  protracted  beyond  the  twentieth  day  the  result 
was  due  to  some  complication.  The  attack  may,  however,  be  prolonged 
to  four,  five,  or  six  weeks,  but  this  is  always  in  consequence  of  complica- 
tions. The  convalescence  may  be  stated  to  be  about  as  long,  as  a  rule, 
as  the  attack,  so  that  an  interval  of  from  four  to  six  weeks  from  the  be- 
ginning of  the  attack  usually  elapses  before  the  patient  is  able  to  return 
to  his  customary  avocation.  The  length  of  the  attack  varies  somewhat 
at  different  periods  of  life,  being  shorter,  as  a  rule,  in  childhood  and  youth 
than  in  middle  or  advanced  age.  The  mean  duration  of  the  attack  has 
been  found  to  be  longer  at  the  beginning  of  an  epidemic  than  toward  its 
close. 

True  relapses  in  typhus  are  extremely  rare. 

The  death-rate  varies  greatly  in  different  epidemics.  Lebert  estimated 
it  to  be  six  or  seven  per  cent,  in  the  Valais  epidemic  in  1839,  while  Jac- 
coud  states  that  in  the  Crimea  and  in  Algiers  the  mortality  has  reached 
from  fifty  to  fifty-five  per  cent.  Outbreaks  in  camps  and  armies,  and 
those  following  severe  famine,  have  invariably  been  attended  with  a 
In'gher  death-rate  than  those  affecting  the  civil  community  under  more 
fortunate  circumstances.  Griesinger  computes  the  mean  mortality  at 
from  fifteen  to  twenty  per  cent.  Not  only  does  the  mortality  vary  in 
different  epidemics,  but  it  also  varies  in  different  years  of  the  endemic 
prevalence  of  typhus.  Thus,  we  find,  upon  consulting  the  statistics  of  the 
London  Fever  Hospital,  that  the  average  mortality  for  23  years  was  18.92 
per  cent.,  or,  deducting  68G  cases  fatal  within  forty-eight  hours,  15.76  per 
cent.;  but  that,  in  the  year  1857,  the  mortality  was  25.18  percent.,  in  1858 
it  was  60  per  cent.,  in  the  year  1859  it  was  33.33  per  cent.,  while  in  1860 
it  was  40  per  cent.,  the  admissions  in  these  years  being  respectively  274, 
15,  48,  and  25. 

The  mortality  in  any  community  is  lower  than  the  mortuary  reports 
of  its  hospitals  would  indicate.  Cases  occurring  in  the  higher  walks  of 
life,  among  children,  and  mild  cases,  are  less  likely  to  become  the  subjects 
of  hospital  statistics  than  those  occurring  among  the  destitute,  those  en- 


TYPHUS    FEVER. 


291 


feebled  by  privation,  and  the  aged  and  infirm  inmates  of  poor-houses,  and 
the  like.  Murchison  estimates  that  the  mortality  in  London,  allowance 
being  made  for  these  sources  of  fallacy,  does  not  probably  exceed  ten  per 
cent. 

Sex  influences  the  mortality.  In  childhood  the  number  of  deaths  is 
comparatively  greater  among  females  than  among  males;  but,  after  tlie 
fifteenth  year,  typhus  appears  to  be  somewhat  more  fatal  in  males  than  in 
females.  The  difference  in  adult  life  is  probably  due  to  the  greater  preva- 
lence of  the  alcoholic  habit  in  the  male  sex,  and  the  greater  consequent 
liability  to  morbid  conditions  of  the  liver  and  kidneys. 

Age  is  of  gTeat  importance  as  influencing  the  death-rate.  In  child- 
hood and  youth,  typhus  is  by  no  means  a  fatal  malady.  In  old  age,  on 
the  contrary,  it  is  most  mortal,  and  the  death-rate  progressively  rises 
from  the  earliest  to  the  latest  periods  of  life. 

I  have  rearranged  one  of  the  tables  of  the  London  Fever  Hospital 
statistics  given  by  Dr.  Murchison,  so  as  to  show  the  number  of  admissions 
in  each  of  the  decades  of  the  years  of  life  in  18,268  typhus-patients,  and 
the  corresijonding  deaths  and  percentage  of  mortality: 

There  were  under  10  years  1,430  cases. 


10 

and 

20 

<( 

5,121 

20 

30 

(( 

4,127 

30 

40 

a 

2,976 

40 

50 

a 

2,546 

50 

60 

a 

1,231 

60 

70 

a 

588 

70 

80 

ii 

116 

58  deaths, 

or       4.05  per  cent 

171 

3.33 

K 

510 

12.35 

( 

690 

23.18 

tc 

906 

35.58 

{ 

630 

51.17 

( 

383 

65.13 

I 

88 

75.86 

c 

3 

100.00 

i 

8 

6.15 

i 

"  80  years  and  upwards,       3     " 
Age  doubtful,  130     " 

In  the  Breslau  epidemic  of  1868-69,  Lebert  found  that  the  disease  be- 
came more  fatal  with  advancing  years,  as  is  shown  by  the  following  table: 


Age. 


Under  15  years 

From  15  to  20  years 
From  20  to  30  years 
From  30  to  40  years 
From  40  to  50  years 
From  50  to  60  years 


Percentage  of 

Percentage  of 

all  cases. 

total  mortality. 

15.2 

2.7 

16.1 

3.16 

22.8 

15 

23 

26 

13.4 

24.1 

7.4 

20 

As  in  other  epidemic  diseases,  the  mortality  is  greatest  at  the  begin- 
ning and  height  of  epidemics,  and  gradually  declines  as  the  number  of 
cases  diminishes. 


292  THE  CONTINUED  FEVERS. 

Race  and  nationality  exert  but  little  influence  upon  mortality.  In 
Philadelphia,  in  the  epidemic  of  1836,  the  mortality  was  greater  among 
the  blacks  than  among  the  white  population  (Gerhard). 

Among  individual  peculiarities  unfavorably  influencing  the  prognosis, 
are  intemperate  habits,  diseases  of  the  kidney,  gout,  obesity,  and  mental 
depression.  Fatigue  and  privation  before  and  at  the  beginning  of  the  at- 
tack, increase  the  danger.  Nursing  women,  according  to  Dr.  Murchison, 
are  prone  to  a  high  degree  of  antemia,  and  in  them  the  chances  of  death 
by  asthenia  are  increased. 

During  the  attack  a  presentiment  of  death  is  of  ominous  prognostic 
import.  It  is  not,  however,  a  necessarily  fatal  sign.  It  is  apt  to  be  pres- 
ent among  persons  of  cultivated  intelligence,  and  in  particular  among 
medical  men.  The  danger  may  be  said  to  be  in  general  terms  proportion- 
ate to  the  severity  of  the  cerebral  symptoms  and  to  the  early  date  of  their 
appearance.  Thus,  severe  headache,  constant  and  high  delirium,  profound 
stupor,  indicate  great  danger,  and  the  earlier  their  appearance  the  greater 
their  significance.  Extreme  prostration,  especially  early  in  the  course  of 
the  disease,  is  a  bad  sign.  So  also  is  tremulousness,  twitching  of  the 
muscles  and  tendons,  and  grasping  in  the  air.  That  condition  of  com- 
plete unconsciousness  with  wide  open  eyes,  to  which  the  name  coina  vigil 
has  been  applied,  is  almost  always  the  forerunner  of  death.  Sleepless- 
ness, alternating  with  delirium,  and  protracted  some  days  without  relief, 
is  most  unfavorable.  An  extremely  rapid  pulse  is  unfavorable,  especially 
if  it  be  undulatory,  small,  or  irregular.  Death  sometimes  occurs,  how- 
ever, in  cases  in  which  the  pulse  has  not  risen  above  100.  A  moderate 
fall  in  the  pulse  is  usually  of  favorable  import.  A  very  faint,  or  inaudi- 
ble systolic  heart-sound,  and  a  feeble  or  imperceptible  impulse,  are  indica- 
tive of  danger.  As  a  general  rule,  the  copiousness  of  the  eruption  is  in 
proportion  to  the  danger  of  the  case,  particularly  if  it  be  at  the  same  time 
dark  or  livid.  On  the  other  hand,  cases  attended  by  a  scant  eruption  of 
light  color  or  by  none  at  all,  are  commonly  favorable.  To  this  statement, 
however,  we  must  make  the  exception  that  Lebert  states  that  he  has  seen 
severe  and  even  fatal  cases  without  eruption.  If  the  temperature  rise 
very  high,  above  41°  C.  (105.8°  F.),  or  if  it  fails  to  fall  during  the  second 
week,  this  is  to  be  regarded  as  of  unfavorable  import.  The  presence  of 
complications  influences  the  prognosis  unfavorably.  Among  the  more 
serious  of  the  many  complications  of  typhus  may  be  mentioned  previously 
existing  or  recent  renal  disease,  pyseinia,  parotid  and  other  bubonic 
swellings,  gangrene,  bed-sores,  erysipelas,  and  diseases  of  the  respiratory 
tract. 

Death  may  take  place  at  any  period.  It  commonly  occurs  toward  the 
end  of  the  second  week,  that  is,  about  the  period  of  the  crisis,  in  uncom- 
plicated cases,  by  asthenia  in  consequence  of  degeneration  of  the  cardiac 
muscular  tissue;  or  by  coma  resulting  from  the  retention  in  the  blood  of 


TYPHUS    FEVER.  293 

the  waste  products  due  to  the  fever-process;  or,  where  pulmonary  compli* 
cations  exist,  in  consequence  of  asphyxia. 

In  the  majority  of  cases  the  fatal  result  is  due  to  some  complication. 

Anatomical  Lesions. 

Emaciation  Is  usually  not  marked  in  the  cadaver,  unless  death  has 
taken  place  after  the  termination  of  the  second  w^eek. 

Post-mortem  rigidity  is  usually  of  short  duration,  and  decomposition 
of  the  body  takes  place  more  rapidly  after  death  from  typhus  than  in  most 
other  diseases  occurring  at  the  same  time  of  the  year.  The  integuments 
of  the  dependent  parts  of  the  body  shove  more  or  less  extensive  and  deep 
discoloration.  The  whole  surface,  including  the  face,  is  not  unfrequently 
livid.     If  death  occur  during  the  fever,  traces  of  the  eruption  often  persist. 

The  muscles  have  usually  lost  their  normal  red  color,  and  show  a  dirty, 
brownish  red,  or  grayish  red  discoloration.  Upon  microscojjical  examina- 
tion, the  muscular  tissue  of  the  heart  and  the  voluntary  muscles  are  found 
to  have  undergone  granular  and  waxy  degeneration,  particularly  if  death 
has  occurred  after  the  end  of  the  second  week.  Extravasations  of  blood 
are  met  with  in  the  substance  of  the  rectus  abdominis  and  other  muscles. 

The  mucous  membrane  of  the  digestive  tract  shows  no  characteristic 
lesion.  The  stomach,  in  a  large  proportion  of  the  cases,  presents  no 
changes  excepting  those  incident  to  slight  catarrh,  namely,  patches  of 
vascular  injection  and  softening.  Minute  ecchymoses  are  also  occasion- 
ally encountered.  The  enlargement  and  ulceration  of  the  solitary  and 
agminate  glands  of  the  intestine,  which  are  constant  in  enteric  fever,  are 
not  encountered  in  typhus.  Exceptionally  the  glands  are  slightly  more 
prominent  than  in  health,  as  is  the  case  after  death  in  various  otlier  dis- 
eases, and  Lebert  states  that  the  solitary  glands,  as  well  as  Peyer's  patches, 
are  occasionally  the  seat  of  minute,  isolated,  superficial  ulcers,  especially 
in  the  vicinity  of  the  ileo-caecal  valve.  The  mesenteric  glands  are  excep- 
tionally slightly  enlarged. 

Degenerative  changes  in  the  kidneys  are  not  uncommonly  found,  as 
the  result  of  pre-existing  renal  disease,  at  the  examination  of  the  bodies 
of  those  dead  of  typhus.  The  traces  of  recent  disease  are  also  of  very 
common  occurrence.  The  kidneys  are  usually  hyperj^mic,  the  cortex  is 
swollen,  opaque,  and  fatty,  and  the  tubules,  upon  microscopical  examina- 
tion, are  found  blocked  with  granular  epithelium  sometimes  commingled 
with  blood-corpuscles.  Occasionally  the  kidneys  are  decidedly  enlarged 
and  gorged  with  blood,  presenting  the  appearances  met  with  in  acute, 
scarlatinal  nephritis. 

Enlargement  of  the  spleen  is  the  rule,  being  present  in  about  three- 
fourths  of  the  cases.  This  organ  is  often  softened;  in  many  instances  it 
is  pulpy,  and  not  rarely  difHuent,  when  the  capsule  is  divided.     Extrava- 


294  THE  CONTINUED  FEVERS. 

sations  of  blood  into  the  tissue  of  the  spleen  are  not  uncommon.  "When 
the  softening  is  less  marked,  the  corpuscles  of  Malpighi  are  enlarged  and 
unusually  distinct. 

The  liver  is  not  unfrequently  slightly  enlarged.  It  is  hypersemic  if 
death  occur  before  or  at  the  time  of  the  critical  defervescence.  If  the 
sickness  has  been  prolonged  into  the  second  vs^eek,  the  liver  is  often  pale, 
fatty,  and  friable.  Its  cells  are  found  to  contain  an  excessive  amount  of 
fat-globules  and  fine  granules.  In  rare  instances  the  liver,  even  when  ex- 
amined shortly  after  death,  has  been  found  emphysematous,  crepitating, 
and  containing  a  frothy  liquid  with  bubbles  of  gas,  portions  of  it  floating 
when  thrown  upon  the  surface  of  water.  This  condition  is  due  to  rapid 
local  decomposition.  The  pancreas  has  frequently  been  found  hyperaemic 
and  slightly  enlarged. 

Peritonitis  is  among  the  rarest  of  the  complications  of  typhus  fever. 
In  one  instance  it  was  due  to  the  bursting  of  a  softened  embolic  deposit 
in  the  spleen.  Occasionally  subperitoneal  ecchymoses  are  encountered. 
Pericarditis  and  endocarditis  are  exceedingly  rare.  There  is  usually  a  con- 
siderable amount  of  serum  in  the  pericardium.  The  changes  in  the  heart 
are  similar  to  those  of  enteric  fever.  It  is  soft,  flaccid,  easily  torn,  and  the 
muscular  tissue  is  of  a  brownish  yellow  color.  These  changes  are  most 
marked  when  death  has  taken  place  late  in  the  course  of  the  disease.  In 
some  instances  they  are  restricted  to  the  left  side  of  the  heart. 

The  blood  found  in  the  heart  and  larger  vessels  is  sometimes  fluid, 
sometimes  coagulated  into  a  black,  pultaceous  clot.  Pale  coagula  are 
very  rarely  found. 

The  bronchial  tubes  exhibit  the  signs  of  recent  catarrhal  inflammation; 
they  are  almost  constantly  injected,  and  contain  a  secretion  varying  from 
thin  mucus  to  thick  pus.  Patches  of  atelectasis  are  common  as  a  result 
of  capillary  bronchitis.  The  dependent  portions  of  the  lungs  are  usually 
deeply  hyperaemic.  Pulmonary  oedema  is  frequent.  True  pneumonia  is 
occasionally  met  with,  and  gangrene  of  the  lung  is  far  from  uncommon. 

Subpleural  ecchymoses  occur.  Pleurisy  is  rare.  When  present,  it  is 
commonly  fibrinous,  and  probably  secondary  to  inflammatory  processes  in 
the  lungs.  When  serous,  it  is  apt  to  become  purulent.  The  bronchial 
glands  are  sometimes  swollen. 

The  brain  and  nervous  system,  notwithstanding  the  prominence  of  the 
nervous  symptoms  of  the  disease,  present  no  characteristic  changes.  If 
death  take  place  early,  there  is  vascular  injection  of  the  membranes  and  some 
hypersemia  of  the  substance  of  the  brain.  If  it  take  place  late,  the  mem- 
branes and  brain-substance  are  annemic,  and  there  is  an  accumulation  of 
serum  in  the  subarachnoid  space  and  in  the  ventricles.  Hemorrhage  into 
the  arachnoid  space  belongs  to  the  rarer  lesions  of  typhus.  It  gives  rise 
to  the  formation  of  a  delicate,  filmy  clot,  usually  extended  over  some  part 
or  the  whole  of  the  convexity  of  the  brain.      Its  source  has  not  yet  been 


TYPHUS    FEVER.  295 

discovered.  The  quantity  of  fluid  present  within  the  cranium  in  typhus 
is  not  greater  than  that  usually  found  in  persons  of  an  advanced  age,  or 
who  have  died  from  wasting  diseases  (Murchison).  The  fluid  occupying 
the  ventricles  and  subarachnoid  space  is  not  to  be  looked  upon,  any  more 
than  is  the  vascular  injection  previously  spoken  of,  as  the  result  of  inflam- 
mation. The  former  accumulates  mechanically  to  fill  up  the  space  within 
the  cranium  occasioned  by  wasting  of  the  brain-substance:  the  latter  is 
likewise  passive  or  mechanical,  and  is  not  greater  or  more  common  than 
in  death  from  other  acute,  febrile  diseases.  Moreover,  there  is  no  direct 
relation  between  the  amount  of  the  vascular  injection,  or  the  quantity  of 
the  fluid,  and  the  gravity  of  the  symptoms  during  life. 

Anatomically,  typhus  fever  presents  no  characteristic  lesion.  At  the 
autopsy  we  encounter  the  changes  due  to  prolonged,  intense  pyrexia, 
namely,  nutritive  disturbances,  a  tendency  to  fatty  degeneration  of  the 
muscles  and  the  glandular  viscera,  and  disintegration  of  the  blood,  with 
diminished  volume  of  the  brain-substance  and  increase  of  intracranial 
fluid.  To  these  we  must  add  frequent  and  grave  lesions  of  the  organs  of 
respiration,  and,  in  the  greatest  number  of  cases,  enlargement  and  soften- 
ing of  the  spleen. 


Diagnosis. 

The  direct  diagnosis  of  typhus  fever  must  remain  doubtful  in  most 
cases  until  the  appearance  of  the  eruption.  Of  diagnostic  importance 
are  the  abrupt  onset,  headache,  extreme  lassitude,  the  tendency  of  the 
fever  to  rapidly  augment.  If  the  disease  be  epidemic,  or  if  the  patient 
presenting  these  symptoms  be  known  to  have  been  exposed  to  the  con- 
tagion of  typhus,  the  diagnosis  is  probable.  It  becomes  certain  upon  the 
appearance  of  the  eruption.  The  critical  defervescence  about  the  four- 
teenth day  is  characteristic. 

The  differential  diagnosis  between  typhus  and  the  following  diseases, 
namely:  enteric  and  relapsing  fevers,  tropical  remittent  fever,  cerebro- 
spinal fever,  measles,  the  plague,  and  alcoholism,  requires  some  words  of 
consideration. 

The  chief  points  of  contrast  between  enteric  fever  and  typhus  and  re- 
lapsing fevers  are  arranged  in  a  tabular  form  upon  page  338.  They  are 
so  manifest  that  it  would  appear  impossible  to  confound  these  affections, 
yet  it  is  to  be  borne  in  mind  that  these  three  fevers  have  been  regarded 
as  essentially  the  same  until  within  a  few  decades,  and  that  they  are  now 
very  generally  regarded,  by  continental  physicians,  as  varieties  of  a  com- 
mon fever.  Moreover,  all  the  symptoms  are  not  always  present;  and  ex- 
ceptionally a  symptom  characteristic  of  one  may  appear  in  another  of 
these  diseases,  as,  for  example,  we  may  meet  with  constipation  in  typhoid 


290  THE    CONTINUED    FEVERS. 

fever  and  with  diarrhoea  in  typhus.     Even  the  eruption  may  be  mixed,  as 
is  seen  in  the  following  case,  reported  by  Da  Costa: 

A  boy,  sixteen  years  of  age,  was  received  into  the  Philadelphia  Hospital  with  evi- 
dent signs  of  the  beginning  of  a  fever  of  low  type.  A  day  or  two  after  his  admission, 
and  corresponding,  as  nearly  as  could  be  ascertained,  to  the  fifth  day  of  the  disease, 
an  eruption  showed  itself  all  over  the  body.  It  was  dark-colored,  petechial  in  its  as- 
pect, and  did  not  disappear  on  pressure.  Associated  with  it  were  drowsiness  and  con- 
stipation. In  a  few  days  more,  however,  the  symptoms  changed  :  the  dark  eruption 
faded  and  rose-colored  spots  were  perceptible  on  the  chest  and  abdomen  ;  diarrhoea  set 
in,  and  the  fever  ran  its  course  to  a  favorable  termination— with  the  character  of  ty- 
phoid, just  as  at  the  outset  it  had  assumed  the  character  of  typhus. 

Similar  cases  have  been  recorded  by  other  competent  observers, 
among  whom  may  be  named  Murchison,  Peacock,  and  T.  J.  Maclagen. 

Ranittent  fever,  in  its  ordinary  form,  as  met  with  in  this  country,  bears 
but  little  resemblance  to  typhus;  but  the  inalignant  remittents  of  tropical 
and  subtropical  climes  occasionally  present  strong  resemblances  to  it. 
They  are  attended  with  great  prostration,  low,  muttering  delirium,  dry, 
brown  tongue,  a  feeble  pulse,  contracted  pupils,  and  in  some  instances  by 
petechial  eruptions.  Typhus  is,  however,  rare  in  the  countries  where  re- 
mittents of  this  form  make  their  home.  Remittent  fever  is  not  conta- 
gious. It  is  apt  to  be  associated  with  pure  intermittents  and  other 
forms  of  disease  due  to  malaria.  Moreover,  true  remissions  do  not  occur 
in  typhus.  And  the  ]  eculiar  eruption  of  typhus  is  never  met  with  in  re- 
mittent fever.  The  enlargement  of  the  spleen  in  malarious  diseases  is  not 
only  much  greater,  but  it  is  also  more  dense  than  that  of  typhus.  Finally, 
the  course  of  typhus  fever  is  uninfluenced  by  antiperiodic  remedies. 

The  differential  diagnosis  between  cerebro-spinal  fever  and  typhus  is 
to  be  found  elsewhere.      (See  page  96.) 

Measles  and  typhus  in  children  present  some  points  of  resemblance, 
the  most  important  of  which  relate  to  the  appearance  of  a  somewhat  sim- 
ilar eruption  about  the  fourth  day  of  each  disease.  The  eruption  of 
measles  is,  as  a  rule,  brighter  in  its  tints,  and  the  pre-eruptive  stage  of 
measles  lacks  the  intensely  febrile  character  which  belongs  to  that  of  ty- 
phus. Moreover,  in  measles,  coryza  and  cough  are  constant,  whereas  the 
more  serious  bronchial  affection  of  typhus  is  insidious  and  often  attended 
with  but  little  cough.  Furthermore,  the  eruption  of  typhus  passes 
through  a  typical  course,  subsiding  speedily  into  maculos  or  stains  which 
do  not  fade  upon  pressure.  The  diagnosis,  if  doubtful,  may  be  simplified 
by  an  examination  of  other  individuals  in  the  household  of  the  affected 
person.  In  this  country  measles  is  peculiarly  a  disease  of  childhood,  where- 
as typhus  is  apt  to  attack  the  adult  members  of  the  household  before  the 
children. 

The  resemblance  between  typhus  and  the  true  plague,  as  it  is  known 


TYPHUS    FEVER.  297 

to  us  by  description,  is  most  close.  Both  are  highly  contagious  diseases, 
of  abrupt  onset,  attended  by  grave  cerebral  symptoms  and  petechial  erup- 
tions. In  the  plague,  however,  nausea  and  vomiting,  a  pale  face,  an 
anxious  expression,  blood-spitting,  and  the  early  appearance  of  glandular 
swellings  with  suppuration  and  the  simultaneous  improvement  in  the 
cerebral  symptoms,  are  met  with.  Moreover,  the  duration  of  the  plague 
is  much  shorter  than  that  of  typhus,  death  taking  place  commonly  between 
the  third  and  fifth  dav,  and  convalescence  beg-innins*  about  the  close  of 
the  first  or  the  beginning  of  the  second  week. 

Certain  forms  of  alcoholism  are  attended  by  a  trembling  delirium 
which,  in  itself,  cannot  be  distinguished  from  the  delirium  tremens  met  with 
at  times  in  typhus.  The  history  of  the  case  is  of  diagnostic  value.  More- 
over, in  alcoholism  the  tongue  is  moist,  the  skin  is  leaky,  there  is  no  erup- 
tion, and  the  temperature  is  but  slightly  elevated,  if  it  be  elevated  at  all. 

Treatment. 

Prophylactic  treatment  is  of  importance,  both  as  regards  communities 
and  individuals.  It  embraces  the  measures  belonging  to  personal  and 
public  hygiene.  Thus,  typhus  is  no  longer  popularly  known  as  ship  or  jail 
fever,  for  public  opinion  and  legal  enactments  have  enforced  the  observ- 
ance of  decent  sanitary  regulations  where  large  numbers  of  ignorant  or 
destitute  individuals  are  crowded  together  in  confinement.  Improvement 
in  the  sanitary  condition  of  these  localities,  formerly  infested  with  typhus 
fever,  has  led  to  its  disappearance  as  an  endemic  disease,  -while  the  great 
epidemics  of  typhus  have  become,  even  in  the  wars  of  recent  times,  almost 
unknown. 

The  armies  of  the  two  greatest  military  movements  since  the  Napo- 
leonic campaigns,  namely,  the  American  and  the  Franco-Prussian  war, 
escaped  its  ravages. 

It  is  impossible  to  prevent  the  importation  of  the  germs  of  typhus  fever 
into  any  locality.  The  object  of  prophylaxis  is  to  reduce  to  a  minimum 
the  conditions  which  favor  the  outbreak  and  extension  of  the  disease. 
These  conditions  are  overcrowding,  destitution,  and  their  attendant  evils — 
filth,  both  of  person  and  dwellings,  foul  air,  and  the  like.  Typhus  never 
makes  its  first  appearance  in  the  cleanly  and  well-ventilated  homes  of  the 
opulent  classes.  If  it  extend  to  them  at  all,  it  is  by  spreading  from  less 
fortunate  localities.  The  deduction  from  this  observation  is  obvious.  Both 
in  season  and  out  of  season,  but  especially  wherever  typhus  has  shown 
itself,  the  strictest  hygienic  regulations  ought  to  be  enforced.  Upon  the 
outbreak  of  an  epidemic,  the  isolation  of  the  first  cases  in  hospitals,  and  the 
thorough  cleansing  and  ventilation  of  the  houses  and  rooms  from  which 
they  are  removed,  with  general  sanitary  measures  to  obviate  the  predis- 
posing causes  of  the  fever  in  the  affected  neighborhood,  are  important. 


298  THE    CONTINUED    FEVERS. 

If  it  is  possible,  the  infected  buildings  should  be  thoroughly  fumigated 
with  sulphur,  ventilated,  whitewashed,  and  allowed  to  stand  unoccupied 
for  a  considerable  time.  The  clothes  and  belongings  of  the  patients 
should  likewise  be  disinfected  by  prolonged  exposure  to  heat,  or  to  the 
fumes  of  burning  brimstone,  or  by  boiling  in  water  containing  carbolic 
acid.  The  infected  bedding  should  be  subjected  to  the  same  treatment, 
and  the  materials  used  for  filling  mattresses  and  pillows  should  be  burned. 
Absolute  cleanliness  in  the  sick-room  is  to  be  insisted  upon.  The  excre- 
tions should  be  promptly  disinfected.  Persons  in  attendance  upon  the 
sick  must  be  allowed  opportunities  for  proper  rest  and  exercise  in  the 
open  air,  and  they  should  be  made  aware  of  the  importance  of  thorough 
ventilation  in  diminishing  the  danger  of  contagion. 

The  general  management  of  typhus  fever  is  the  same  as  that  of  en- 
teric, regard  being  had  to  the  early  and  grave  adynamia  which  so  often 
characterizes  the  affection  under  consideration. 

Hygienic  measures  relate  to  ventilation,  to  cleanliness,  and  to  diet. 
Typhus  cases,  when  treated  in  hospital,  should  be  placed  in  large  rooms 
by  themselves,  and  never  more  than  four  or  six  together  ;  the  windows, 
even  in  winter,  should  be  kept  open  so  as  to  secure  careful  and  thorougli 
ventilation.  All  observers  insist  that  bad  air  is  more  to  be  dreaded  than 
cold.  When  cases  are  treated  at  their  homes,  as  is  necessary  in  the  well- 
to-do  classes,  similar  regulations  are  to  be  observed  ;  and  in  particular, 
all  unnecessary  furniture,  and  all  curtains  and  hangings  which  are  liable 
to  interfere  with  ventilation,  on  the  one  hand,  and  to  absorb  and  retain 
the  contagion,  on  the  other,  are  to  be  taken  away.  Quietude  is  to  be 
observed,  and  all  visits,  except  such  as  are  absolutely  necessary,  are  to  be 
prohibited. 

Moderate  quantities  of  milk  and  arrow-root  may  be  given,  as  a  meal, 
morning  and  evening;  and  during  the  twenty-four  hours,  at  intervals  of 
two  hours  during  the  day  and  three  during  the  night,  milk,  or,  in  many 
cases,  milk-punch,  broths,  or  light  soups,  may  be  given  alternately.  If 
the  patient  be  asleep  at  the  time  the  food  is  due,  it  is  important  that  he 
be  not  disturbed.  After  an  hour,  or  an  hour  and  a  half,  if  he  do  not 
awake,  he  may  be  aroused  and  an  increased  amount  of  nourishment  at  once 
administered.  The  thirst  which  distresses  him  may  be  satisfied  with 
water  in  abundance;  or,  if  the  patient  prefer  it,  he  may  occasionally  have 
weak  lemonade  or  carbonic  acid  water.  Cold  sponging  is  usually  agree- 
able to  the  patient,  and  is  useful  for  purposes  of  cleanliness.  It  is  im- 
portant to  control  the  temperature  by  means  of  antipyretics.  Systematic 
cold  bathing  is  stated  by  Lebert  to  be  not  only  well  borne,  but  to  meet 
with  no  opposition  from  the  patient  as  soon  as  a  few  baths  have  been 
taken.  The  rules  to  be  observed  are  the  same  as  those  laid  down  for  the 
hydrotherapeutic  treatment  of  hyperpyrexia  in  enteric  fever.  (See  page 
229.)     In  view  of  the  marked  depression  so  characteristic  of  typhus  fever, 


TYPHUS    FEVER.  299 

it  is  probable  that  the  abstraction  of  heat  by  means  of  cold  baths  will 
be  found  less  applicable  in  this  disease  than  in  other  febrile  diseases  in 
which  adynamia  is  less  prominent.  Wet  packs  may  sometimes  take  the 
place  of  bathing,  or  bags  of  ice,  applied  to  the  abdomen  and  to  the  head, 
will  be  useful  in  reducing,  at  all  events  to  some  extent,  the  temperature. 
Cold-water  injections  are  admissible  in  typhus  fever,  and  are  satisfactory 
in  relieving  constipation.  Large  doses  of  quinine,  1.0 — 2.0  grammes 
(15 — 30  grains)  may  be  employed  to  reduce  temperature.  For  this  pur- 
pose digitalis  may  also  be  given;  and  quinine,  digitalis,  and  hydrothera- 
peutic  measures,  may  be  used  together.  Thus,  the  infusion  of  digitalis 
may  be  given  at  intervals  of  four  hours,  with  an  antipyretic  dose  of 
quinine  once  in  twelve  or  twenty-four  hours,  and  an  occasional  resort  to 
the  wet  pack,  or  the  application  of  ice-bags.  Stimulants  are  very  gen- 
erally required,  but  they  are  to  be  used  with  judgment.  Most  children, 
and  a  large  number  of  the  adult  cases,  may  be  satisfactorily  treated  with- 
out them.  Alcohol  is  seldom  required  before  the  appearance  of  the  erup- 
tion; it  is  most  useful  in  the  second  week,  and  often  necessary  upon  the 
approach  of  the  crisis,  even  in  cases  where  it  has  not  before  been  re- 
quired. Old  people,  and  those  previously  greatly  debilitated,  almost  in- 
variably require  alcoholic  stimulants  in  the  beginning  of  the  disease. 
Persons  of  intemperate  habits  also  commonlj'  require  alcohol  from  the  on- 
set of  the  disease,  and  in  greater  quantities  than  those  unaccustomed  to 
its  use  in  health.  Stimulants  must  be  promptly  given  in  cases  of  great 
prostration,  with  low  delirium  and  a  tendency  to  coma  ;  also  where  the 
systolic  heart-sound  is  faint,  or  when  the  pulse  is  frequent,  feeble,- or  un- 
dulatory.  Here,  as  in  all  low  fevers,  the  first  sound  of  the  heart  and  the 
character  of  the  pulse  are  the  best  indications  for  the  administration  of 
stimulants,  both  as  regards  the  time  and  the  quantity.  Delirium  in  itself 
is  not  necessarily  an  indication  for  the  administration  of  stimulants.  If, 
however,  the  patient  become  calmer  and  more  rational  under  their  use, 
they  are  to  be  continued  or  increased.  No  definite  rules  can  be  laid 
down  as  to  the  quantity  to  be  administered  in  the  twenty-four  hours.  It 
varies  from  an  ounce  or  two,  given  in  tablespoonful  doses  when  the  symp- 
toms seem  to  call  for  it,  to  twelve  or  fourteen  ounces  distributed  through- 
out the  twenty-four  hours,  at  regular  intervals.  Sound  whiskey  or 
brandy  are  the  most  satisfactory  forms  in  which  alcohol  is  given.  The 
English  writers  recommend  the  malt  liquors,  and  state  that  they  are 
agreeable  to  many  patients.  Where  circumstances  permit  its  use,  cham- 
pagne may  be  given.  Among  the  diffusible  stimulants  useful  in  typhus 
are  ammonium  carbonate,  chloroform,  camphor,  and  turpentine.  When 
the  prostration  is  extreme  and  the  patient  is  unable  to  swallow,  brandy, 
or  whiskey,  or  ether  may  be  hypodermically  administered.  As  will  com- 
monly happen  in  the  severest  cases,  the  condition  of  the  patient  may 
render  it  impossible  to  give  the  necessary  food  by  the  mouth.      Under 


300  THE    CONTHSrUED    FEVlfiliS. 

such  circumstances,  an  endeavor  to  support  the  patient's  strength  and  to 
prolong  life  must  be  made  by  means  of  rectal  alimentation  and  medica- 
tion. 

It  is  of  the  utmost  importance  that  the  patient's  strength  be  hus- 
banded from  the  beginning  of  his  sickness.  All  mental  and  bodily  effort 
is  to  be  avoided.  It  is  a  common  observation  that  those  who  struggle 
against  the  disease  in  its  early  days  usually  suffer  from  great  prostration 
later.  The  patient  should  betake  himself  to  his  bed  as  soon  as  the 
fever  appears.  If  there  be  marked  prostration  during  the  first  week, 
and  under  most  circumstances  during  the  remainder  of  his  illness,  the  pa- 
tient should  not  get  out  of  bed  for  any  purpose.  Many  persons,  partic- 
ularly men,  object  to  using  the  bed-pan.  In  typhus  it  is,  in  many  cases, 
imperative  that  the  patient  do  not  assume  the  upright  position.  Fatal 
syncope  may  result.  The  management  of  the  patient  in  delirium  will 
often  tax  the  patience  and  tact  of  the  nurse  to  their  utmost.  In  most 
cases  restraint  by  forcible  measures  is  unnecessary;  it  is  always  a  last 
resort,  and  to  be  deplored. 

When  we  come  to  speak  of  the  treatment  of  typhus  fever  by  medicine, 
we  find  that  no  drug  or  course  of  medication  is  adequate  either  to  arrest 
or  to  shorten  the  course  of  the  primary  disease.  The  sufferings  of  the 
patient  may  be  mitigated,  and  the  attendant  complications  to  some  de- 
gree warded  off  or  controlled,  when  they  arise,  by  a  watchful  attendance 
and  judicious  therapy;  but  this  is  all.     No  cure  for  typhus  is  known. 

The  mineral  acids  occupy  the  highest  rank  among  the  medicines  em- 
ployed in  the  treatment.  Nitro-muriatic  acid  is  usually  preferred  in  this 
country.  Da  Costa  gave  it  in  three  to  five  drop  doses,  either  alone,  or  al- 
ternately with  turpentine,  when  pulmonary  complications  were  present. 
If  the  latter  became  prominent,  the  acid  was  discontinued  and  turpentine 
given  in  connection  with  quinine,  and  applied  externally  in  the  form  of 
stupes  to  the  chest. 

Most  of  the  complications,  the  pneumonias,  and  parotid  swellings, 
were  treated  by  turpentine  and  quinine,  and  stimulants. 

Lebert,  who  regards  drugs,  as  such,  unnecessary,  gives  the  following 
as  a  placebo: 

^.    Acid,  phosphor,  dil 4-8  c.c.  fl.  3  j.-ij. 

Syrupi 32  c.c.  fl.  3  j. 

Aquae 160  c.c.  fl.  3  v. 

M.     Signa. — A  tablespoonful  q.  s.  h. 

Headache  is  to  be  treated  by  cold  applications,  or  by  external  warmth, 
or,  if  it  be  distressing  and  the  subject  young  and  robust,  by  two  or  three 
leeches  applied  to  the  edges  of  the  hair  on  the  temples. 

Sleeplessness,  nervous  excitement,  and  delirium,  require,  in  many  cases, 
special  treatment.     Much   may   be  done  toward  their  alleviation  by  the 


TYPHUS   FEVEE.  301 

skilful  management  of  the  sick-room  and  the  personal  ministrations  of 
the  nurse.  Chloral,  opium  and  its  derivatives,  especially  in  combination 
with  minute  doses  of  belladonna  or  atropine,  and  the  diffusible  stimulants, 
are  to  be  employed.  Camphor,  alone  or  in  combination  with  morphia, 
or  with  tartar-emetic,  opium,  and  musk  (Graves),  is  highly  lauded  against 
the  subsultus,  tremors,  and  delirium.  It  is  necessary  to  call  attention  to 
the  danger  of  chloral  in  large  doses  where  there  is  any  tendency  to  failure 
of  the  heart. 

Stupor,  if  marked,  may  be  treated  by  small  cupfuls  of  strong  coffee, 
repeated  at  intervals  of  three  or  four  hours.  Cold  affusions  may  become 
necessary.  Stimulating  rectal  injections  containing  turpentine  may  be 
administered.  They  are  additionally  useful  as  provoking  the  action  of 
the  bowels. 

The  complications  of  typhus  are  to  be  treated  in  accordance  with  gen- 
eral therapeutic  principles.  It  is  probable  that  suppurative  inflammation 
of  the  parotid  and  its  overlying  tissues,  and  similar  processes  elsewhere 
in  the  body,  will  prove  less  generally  fatal  than  formerly,  if  promptly 
treated  by  the  evacuation  of  the  pus,  and  antiseptic  dressings  in  accord- 
ance with  the  rules  laid  down  by  Prof.  Lister. 

Coiwalescence  is  commonly  steadily  progressive,  and  rapid,  unless 
complications  retard  it.  For  a  few  days  the  diet  is  to  be  restricted,  both 
as  regards  quantity  and  kind,  as  the  appetite  is  often  ravenous  and  there 
is  danger  of  excess.  Barks,  iron,  quinine,  and  perhaps  best  of  all,  cod- 
oii,  should  be  given  if  the  patient  remain  feeble  and  pale.  Sleeplessness 
is  to  be  obviated  by  judiciously  chosen  hypnotics.  The  patient  must  be 
warned  against  the  risks  incurred  by  too  great  haste  to  resume  his  occu- 
pation. 


VI. 

RELAPSING  FEVER. 

Definition. — An  acute,  contagious  fever,  rarely  occurring  except  as  an 
epidemic,  and  in  seasons  of  scarcity  of  food;  it  consists  of:  {a)  a  febrile 
paroxysm,  characterized  by  abrupt  onset,  active  fever,  a  moist,  white 
tongue,  epigastric  tenderness,  vomiting,  and  often  jaundice,  enlarge- 
ment of  the  liver  and  of  the  spleen,  and  the  absence  of  eruption,  and 
terminating  suddenly  with  free  perspiration  about  the  fifth  or  sev- 
enth day;  (b)  an  interval  of  complete  apyrexia;  and  (c)  an  abrupt  re- 
lapse, on  or  about  the  fourteenth  day  from  the  beginning  of  the 
disease;  this  relapse  runs  a  course  similar  to  that  of  the  initial  par- 
oxysm, and  comes  to  an  end  by  crisis  on  or  about  the  third  day. 
Convalescence  usually  ensues  upon  the  termination  of  the  relapse, 
but  a  second,  third,  or  even  fourth  relapse,  has  been  observed.  Fatal 
termination  infrequent  ;  enlargement  of  liver  and  spleen,  but  no 
specific  lesion,  found  upon  examination  after  death. 

Synonyms. — Febris  recidiva;  Typhus  recurrens;  Five  days'  fever,  with  re- 
lapses; Short  fever;  Five  days'  fever;  Seven  days'  fever;  Seventeen 
days'  fever;  Fievre  a  rechute;  Typhus  a  rechute;  Das  recurrirende 
Fieber  ;  Wiederkehrendes  Fieber  ;  Riickfalls  Fieber  ;  Armentyphus  ; 
Die  Hungerpest;  Tifo  recidivo. 

Epidemic  fever  of  Edinburgh;  Scotch  epidemic  of  1843;  Epidemic 
fever  of  Ireland  ;  Epidemic  remittent  fever  ;  the  Silesian  fever  of 
1847;  Dynamic  or  inflammatory  fever;  Synocha  or  relapsing  synocha. 

Mild  yellow  fever;  Bilious  relapsing  fever;  Gastro-hepatic  fever; 
Remitting  icteric  fever;  Bilious  typhoid;  Famine  fever. 

Typhinia. 

The  term  Relapsing  Fever  is  derived  from  one  of  the  most  constant 
and  certainly  the  most  striking  peculiarity  of  the  disease.  It  has  passed 
into  general  use.  It  is  sufficiently  distinctive,  and  is  not  open  to  the 
objection  of  embodying  any  theory  regarding  the  origin  or  nature  of  the 
fever. 

The  synonyms  are  very  numerous;  they  have  been  suggested  by  the 
consideration  of  various  particulars  relative  to  the  special  epidemic  preva- 


RELAPSING    FEVER.  303 

lencc  of  the  disease,  to  the  duration  of  the  attack,  to  symptoms  that  are 
prominent,  or  to  a  supposed  relation  between  it  and  typhus.  The  cir- 
cumstances forming  the  basis  of  most  of  them  will  appear  in  the  course 
of  the  following  account  of  the  affection. 


Historical  Sketch. 

Dr  Robert  Spittal  '  in  1844  called  the  attention  of  the  medical  pro- 
fession to  the  fact  that  relapsing  fever  is  not  a  new  disease.  He  showed 
that  the  epidemic  at  that  time  prevailing  in  Scotland  was  exactly  the 
same,  in  all  its  important  features,  as  an  epidemic  described  by  Hippocrates 
as  having  occurred  more  than  twenty  centuries  ago  in  the  island  of 
Thasos,  off  the  coast  of  Thrace.  The  points  of  resemblance  between  the 
ancient  and  the  modern  epidemics  are  :  the  occurrence  of  relapses  after  an 
intermission  of  five  or  seven  days,  the  crisis,  the  copious  perspiration, 
epistaxis,  jaundice,  a  tendency  to  miscarry,  and  the  like. 

Apart  fioni  the  occasional  mention,  by  several  writers,  of  the  occur- 
rence of  one  or  more  relapses  in  the  course  of  continued  fever,  in  the  epi- 
demics which  they  have  described,  and  which  may  or  may  not  refer  to  cases 
of  relapsing  fever  prevailing  in  connection  with  typhus,  there  is  no  definite 
account  of  the  epidemic  prevalence  of  the  fever  under  consideration  prior 
to  the  year  1739.  Dr.  Rutty  ^  chronicled  a  disease  prevalent  in  Dublin 
in  that  year,  in  the  following  words  :  "  The  latter  part  of  July  and  the 
months  of  August,  September,  and  October,  were  infected  with  a  fever, 
which  was  very  frequent  during  this  period,  not  unlike  that  of  the  autumn 
of  the  preceding  year,  with  which  compare  also  the  years,  1741,  1745,  and 
1748.  It  was  attended  with  an  intense  pain  in  the  head.  It  terminated 
sometimes  in  four,  for  the  most  part  in  five  or  six  days,  sometimes  in  nine, 
and  commonly  in  a  critical  sweat;  it  was  far  from  being  mortal.  I  was 
assured  of  seventy  of  the  former  sort  at  the  same  time  in  this  fever,  aban- 
doned to  the  use  of  whey  and  God's  good  providence,  who  all  recovered. 
The  crisis,  however,  was  very  imperfect,  for  they  were  subject  to  relapses, 
even  sometimes  to  the  third  time;  nor  did  their  urine  come  to  a  com- 
plete separation.  Divers  of  them,  as  their  fever  declined,  had  a  paroxysm 
in  the  evening,  and  in  some  these  succeeded  pains  in  the  limbs."  A  little 
farther  on,  after  speaking  of  the  fever  of  the  summer  of  1741,  the  same 
author  says:  "It  seems  also  not  unworthy  of  notice,  that  through  the 
three  summer  months  there  was  frequently  here  and  there  a  fever,  alto- 
gether without  the  malignity  attending  the  former,  of  six  or  seven  days' 

'  The  Antiquity  of  the  Fever  prevalent  in  1843  :  Edinburgh  Monthly  Journal  of 
Medical  Science.     Vol.  iv.,  1844. 

-  A  ChronoloQ^ical  History  of  the  Weather,  Seasons,  and  Diseases  in  Dublin,  from 
1725  to  17(55.     By  John  Rutty,  M.D.     London,  1770. 


304  THE    CONTINUED    FEVERS. 

duration,  terminating  in  a  critical  sweat,  as  did  the  other  also  frequently; 
but  in  this  the  patients  were  subject  to  a  relapse,  even  to  a  third  or  fourth 
time,  and  yet  recovered." 

During  the  epidemic  of  fever  which  prevailed  in  Ireland  from  1797  to 
1803 — a  period  of  great  destitution  among  the  lower  classes — many  cases 
"were  observed,  the  account  of  which  fully  corresponds  to  relapsing 
fever.  We  are  informed  by  Drs.  Barker  and  Cheyne '  that  *'  the  fever 
of  1800  and  1801  very  generally  terminated  on  the  fifth  or  seventh  day 
by  perspiration  ;  that  the  disease  was  then  very  liable  to  recur ;  that 
the  poor  were  the  chief  sufferers  by  it;  and  that  it  was  much  more  fatal 
among  the  middling  and  upper  classes  in  proportion  to  the  number  at- 
tacked." 

Relapsing  fever  prevailed  from  time  to  time  during  the  first  sixteen 
years  of  this  century,  in  Ireland  and  elsewhere,  while  in  all  probability  the 
widespread  epidemic  of  1817-19  was  largely  composed  of  it.  This  great 
outbreak  began  in  Ireland  during  a  period  of  great  scarcity  of  food,  and 
was  carried  into  England  and  Scotland  by  the  migration  of  the  Irish 
poor,  who  flocked  into  the  large  towns,  condensing  their  population,  and 
introducing  habits  of  uncleanliness  and  improvidence  with  the  seeds  of 
disease. 

The  distinction  between  the  two  forms  of  fever,  namely,  relapsing  and 
typhus,  which  composed  this  epidemic,  had  not  then  been  made  ;  they 
■were  regarded  as  modifications  of  one  disease,  and  it  was  a  general  im- 
pression that  the  relapsing  fever  could  produce  common  typhus,  and  vice 
versa.  Dr.  Murchison  *  has,  however,  shown  by  a  critical  study  of  the 
symptoms,  the  death-rate,  and  the  results  of  treatment  by  bloodletting, 
that  relapsing  fever  mainly  constituted  the  epidemic,  and  has  probably 
correctly  inferred  from  the  circumstance  that  the  rate  of  mortality  in- 
creased in  many  places  with  the  advance  of  the  epidemic,  that  the  propor- 
tion of  typhus  to  relapsing  cases  was  greater  toward  the  close  of  the 
epidemic  than  at  its  commencement. 

From  the  subsidence  of  the  epidemic  of  1817-19  till  182G,  there  is  no 
record  of  the  occurrence  of  relapsing  fever.  In  that  and  the  two  following 
years  a  great  outbreak  of  fever  raged  first  in  Ireland,  and  later  in  Scot- 
land and  England.  It  followed  commercial  distress,  and  was  chiefly  con- 
fined to  the  largest  towns.     Dr.  O'Brien,'  who  observed  it  in  Dublin  in 

'  An  Account  of  the  Rise,  Progress,  and  Decline  of  the  Fever  lately  Epidemic  in 
Ireland,  etc.  By  F.  Barker,  M.D.,  and  I.  Cheyne,  M.D.  2  vols.  London  and  Dub- 
lin, 1837. 

-  A  Treatise  on  the  Continued  Fevers  of  Great  Britain.  By  Charles  Murchison, 
M.D.,  LL.D.,  F.R.S.     Second  edition.     London,  1873. 

"Medical  Report  of  the  House  of  Recovery  and  Fever  Hospital,  Cook  Street,  Dub- 
lin, etc.  :  Transactions  of  Kings  and  Queens'  College  of  Physicians  in  Ireland.  Vol.  v. 
Dublin,  1828. 


RELAPSING    FEVER.  305 

1836-27,  states  that  "  at  the  conclusion  of  the  spring  and  commencement 
of  the  summer  (1826)  a  vast  body  of  artisans  residing  in  the  Liberties  of 
Dublin  were  thrown  out  of  employment,  and  actually  labored  under  all 
the  miseries  of  artificial,  yet  positive  famine,  being  destitute  of  the 
means  of  purchasing  food."  This  epidemic,  like  that  of  1817-19,  was 
composed  of  relapsing  and  typhus  fevers,  the  former  being  more  promi- 
nent in  Ireland,  and  at  the  beginning,  and  the  latter  being  much  more 
common  toward  the  end  of  the  epidemic,  which  at  the  last  was  almost 
exclusively  made  up  of  it.  It  was  in  this  epidemic  that  a  correct  dis- 
tinction between  the  two  fevers  was  first  drawn.  Dr.  O'Brien,  in  the 
report  above  cited,  wrote  as  follows:  "At  the  commencement  of  the 
epidemic  two  species  of  fever  were  distinguishable  in  the  wards  of  this 
hospital,  which,  to  use  the  words  of  Sydenham,  we  shall  call  the  fever  of 
the  old  and  the  fever  of  the  new  constitution.  The  first  was  the  ordinary 
typhus  of  this  country,  marked  by  its  usual  protracted  periods,  running 
on  to  the  eleventh,  fourteenth,  seventeenth,  or  twenty-first  days.  This 
species  of  fever  was  far  inferior  in  numerical  amount  to  the  other,  but 
far  more  fatal.  The  other  species  of  fever,  or  that  of  the  new  constitu- 
tion, which  constituted  the  bulk  of  this  epidemic,  was  one  of  short 
periods,  terminating  in  three,  five,  seven  or  nine  days,  but  the  second  of 
these  periods  was  the  most  frequent.  The  patient  was  destined,  perhaps, 
to  be  harassed  by  one,  two  or  three  relapses,  which  prolonged  the  whole 
duration  of  his  illness  beyond  that  of  the  most  protracted  typhus — in  fact, 
the  liability  to  frequent  relapses  was  one  of  the  most  striking  character- 
istics by  which  this  fever  was  distinguished  from  all  previous  epidemics, 
at  least,  which  happened  in  our  time." 

From  1828  till  toward  the  end  of  the  year  1842,  relapsing  fever 
seems  to  have  disappeared  from  the  British  Islands.  So  little  was  it 
known  or  thought  of  during  this  interval,  that  when  it  next  appeared  it 
was  looked  upon  as  a  new  disease  by  many  of  the  physicians  who  first 
encountered  it. 

In  1842,  there  arose  an  extensive  outbreak  of  fever,  which  differed  from 
those  that  had  preceded  it  in  neither  beginning  in  Ireland,  nor  in  spread- 
ing to  that  country.  The  first  cases  were  observed  on  the  east  coast  of 
Fife,  and  not  in  the  large  cities.  The  earliest  cases  in  Glasgow  occurred 
early  in  the  autumn,  and  the  disease  became  generally  prevalent  in  De- 
cember. The  cases  steadily  increased  till  October,  1843,  when  the  epi- 
demic began  to  abate.  The  number  of  cases  is  estimated  at  33,000,  or 
between  ten  and  eleven  per  cent,  of  the  entire  population.  In  Edinburgh 
and  in  Aberdeen  the  disease  made  its  appearance  in  February,  1843,  and 
increased  till  October,  after  which  it  abated  by  degrees,  and  in  the  fol- 
lowing April  had  nearly  ceased.  It  prevailed  generally  over  Scotland, 
and  was  not  restricted  to  the  large  cities.  In  England  its  distribution 
was  chiefly  restricted  to  the  large  cities.  In  this  epidemic  cases  of  re- 
20 


306'  THE   CONTINUED    FEVERS. 

lapsing  fever  largely  preponderated;  typhus  was,  with  the  exception  of  a 
few  localities  at  Dundee,  comparatively  rare,  and  everywhere  the  latter 
fever  increased  with  the  progress  of  the  epidemic.  This  fact  was  clearly 
established  by  the  statistics  of  the  hospitals  and  infirmaries  of  Glasgow 
and  Edinburgh,  where  the  distinction  between  the  two  fevers  was  more 
clearly  recognized. 

Cases  of  relapsing  fever  were  occasionally  encountered  from  the  time 
of  the  subsidence  of  this  epidemic  until  1846.  In  the  last  months  of  that 
j'^ear  there  appeared  in  the  British  Isles  an  epidemic  of  fever  of  great 
magnitude  and  severity.  It  arose  in  Ireland  after  the  failure  of  the  po- 
tato crop,  and  at  a  time  of  great  consequent  famine  and  destitution.  At 
the  end  of  the  year  it  reached  Glasgow;  Edinburgh  in  March;  it  fell  upon 
Liverpool  in  January,  1847,  upon  London  in  March,  upon  Manchester  in 
April.  It  prevailed  very  generally  over  Ireland,  and  in  the  large  towns 
of  Scotland  and  England.  It  reached  its  height  in  the  autumn  of  1847, 
but  did  not  wholly  disappear  till  the  end  of  1848.  In  this  epidemic  the 
cases  of  typhus  constituted  by  far  the  greatest  number  of  the  sick.  En- 
teric fever  was  also  observed,  and  relapsing  fever  was  common.  The 
greater  preponderance  of  the  last-named  fever  in  the  early  part  of  the 
epidemic  was  noted  by  nearly  all  observers.  In  the  greater  number  of 
typhus  cases  which  this  epidemic  presented,  it  had  very  much  the  same 
relation  to  the  epidemic  of  1843  that  the  epidemic  of  1826  had  borne  to 
that  of  1817-19  (Murchison). 

From  the  time  of  the  epidemic  of  1846,  relapsing  fever  has  gradually 
subsided.  In  1851,  there  was  a  local  increase  of  it  in  London,  where  the 
disease  was  almost  exclusively  confined  to  Irish  people,  all  in  a  state  of 
destitution  and  mostly  recently  arrived  from  their  own  country.  At  the 
same  time  the  fever  prevailed  to  some  extent  in  Edinburgh.  In  1853,  it 
was  common  in  Ireland.  In  1855,  it  disappeared,  and,  as  Murchison  informs 
us,  for  fourteen  years  not  a  case  of  relapsing  fever  was  observed  in  any 
hospital  of  Great  Britain,  while  in  Ireland  it  seems  also  to  have  been 
unknown. 

In  1868,  relapsing  fever  reappeared — this  time  in  London,  where  it  at- 
tained its  maximum  in  December,  1869,  and  declined  gradually  till  June, 
1871,  when  it  came  to  an  end.  During  the  time  of  its  prevalence  in 
London  the  fever  showed  itself  also  in  other  large  cities  of  England  and 
Scotland.  In  this,  as  in  former  epidemics,  the  cases  occurred  chiefly 
among  the  poorest  classes  of  the  population;  most  of  the  patients  were 
in  an  extreme  state  of  destitution. 

In  1846-47  there  prevailed  in  Upper  Silesia — a  province  of  Prussia — and 
elsewhere  in  Germany,  an  epidemic  of  fever  which  resembled  that  then 
prevalent  in  the  British  Islands.  It  first  occurred  among  the  Silesians,  a 
people  whose  condition  closely  resembles  that  of  the  Irish  peasantry, 
and  appeared  in  a  time  of  severe  famine.     It  consisted  partly  of  relapsing 


RELAPSING    FEVER.  307 

fever  and  partly  of  typhus.  Griesinger '  states  that  relapsing  fever  also 
probably  formed  part  of  the  epidemic  which  prevailed  in  Bohemia  during 
the  same  year,  and  that  he  encountered  it  in  1851,  in  Egypt,  associated 
with  "  other  forms  of  typhus."  During  the  summer  months  of  1855,  it 
prevailed  among  the  British  troops  in  the  Crimea. 

In  1863,  relapsing  fever  broke  out  at  Odessa;  iu  1864,  it  appeared  in 
St.  Petersburg,  where  it  was  mostly  restricted  to  the  poorest  class  of  the 
people.  Overcrowding  of  the  wretched  habitations  of  the  poor  had  re- 
sulted from  the  influx  of  recently  liberated  serfs  to  the  capital  in  search  of 
work;  food  of  all  kinds  was  at  the  same  time  high  and  bad.  The  pestilence 
followed.  It  was,  as  in  the  epidemics  which  have  been  described  as  occur- 
ring in  Great  Britain  and  elsewhere,  composed  of  mixed  cases  of  relapsing 
fever  and  typhus.  The  number  of  cases  of  the  former  relative  to  those 
of  the  latter  fever  was  much  greater  at  the  beginning  of  the  epidemic. 

Toward  the  close  of  the  year  1867,  relapsing  fever  and  typhus  again 
appeared  together  as  an  epidemic  in  Silesia.  They  prevailed  in  East 
Prussia,  and  spread  in  1868  to  Breslau,  Berlin,  and  other  large  cities  of 
Germany.  This  epidemic  was  generally  ascribed  to  destitution  and  want 
of  food,  but  whether  it  was  an  extension  of  the  epidemic  in  Russia  or  not, 
is  not  clear  (Murchison). 

About  the  close  of  1872,  relapsing  fever  again  broke  out  in  Berlin  and 
in  Breslau.    This  epidemic  prevailed  until  the  close  of  the  following  summer. 

The  disease  reappeared  in  Berlin  in  1879,  and  is  now  (spring  of  1880) 
to  a  slight  extent  prevalent  in  that  capital. 

The  geographical  range  of  relapsing  fever  is  much  wider  than  it  was 
formerly  thought  to  be.  It  has  been  observed  in  greatest  frequency,  and 
has  assumed  its  greatest  importance,  in  the  British  Isles. 

Of  the  numerous  epidemics  that  have  swept  over  these  islands,  all  but 
two  have  originated  in  Ireland.  Of  these,  the  earlier,  which  occurred  in 
1843,  and  has  been  described  as  the  Scotch  epidemic  of  that  year,  arose  in 
Scotland  and  implicated  Ireland  but  little,  if  at  all;  the  second  was  that 
of  1868,  which  first  appeared  in  London  at  a  period  when  there  was  no 
relapsing  fever  in  Ireland.  The  fever  was  then  prevalent  upon  the  Con- 
tinent, and  it  is  probable  that  this  outbreak  was  an  extension  of  the  epi- 
demic in  Germany. 

Beyond  the  limits  of  the  epidemics  already  mentioned  as  having  pre-- 
vailed  in  Upper  Silesia,  North  Germany,  in  Poland,  the  Crimea,  and 
widely  in  Russia,  relapsing  fever  is  not  known  to  have  occurred  in 
Europe,  except  in  a  few  isolated  and  restricted  outbreaks.  Such  minor 
epidemics  have  likewise  been  observed  in  Siberia,  Algiers,  and  on  the  isl- 
and of  Reunion.     This  fever  has  also  occurred  in  India  and  other  tropi- 

'  Virchow's  Handbuch  der  Pathologie  und  Therapie.  XT.  Band,  Abtheilung  11.  Ei- 
langen,  1864. 


308  THE  CONTINUED  FEVERS. 

cal  countries,  and  chiefly  in  connection  with  typhus.  Relapsing  fever  has 
never  appeared  as  an  indigenous  disease  in  America,  It  has  been  im- 
ported on  several  occasions  during  its  epidemic  prevalence  beyond  the 
Atlantic,  but  its  outbreak  has  been,  for  the  most  part  limited,  and  re- 
stricted to  the  cities  of  the  seaboard.  In  June,  1844,  fifteen  cases  of  re- 
lapsing fever  were  transferred  from  a  Liverpool  packet  arriving  in  Phila- 
delphia with  Irish  immigrants,  to  the  Philadelphia  Hospital.  The  disease 
did  not  spread  to  the  attendants  or  the  other  patients  in  the  hospital, 
although  the  cases  were  not  isolated.  Two  women,  sisters  of  one  of  the 
immigrants,  who  had  been  for  a  long  time  resident  in  the  city,  contracted 
the  fever  and  were  afterward  admitted  to  the  hospital.  No  other  cases 
occurred.^  The  disease  appeared  in  a  like  restricted  manner  in  New  York 
in  1848,''  and  in  1850-51,  Professor  Austin  Flint'  observed  fifteen  cases  of 
fever  among  recently  arrived  Irish  immigrants  in  the  hospital  at  Buffalo, 
which,  upon  subsequent  examination  of  the  notes,  proved  to  be  undoubted 
instances  of  relapsing  fever.  At  the  same  period  more  numerous  cases 
were  observed  in  Canada.  In  1869,  it  again  appeared  in  America,  the  first 
cases  being  observed  in  Philadelphia  in  September,^  and  in  New  York  in 
November.^  The  greater  number  of  the  patients  was  among  the  poor  of 
the  Irish  and  German  population.  The  disease  was  thought  to  have  been 
imported,  but  from  what  source  remains  unknown.  Dr.  Parry,  who  first 
encountered  it  in  Philadelphia,  and  who  carefully  investigated  this  out- 
break, states  that  every  attempt  to  trace  the  origin  of  the  earliest  cases 
failed.  The  disease  spread  slowly  among  the  most  destitute  of  the  popu- 
lation, reaching  its  height  about  the  middle  of  the  following  year  (1870) 
and  then  rapidly  subsided.  It  had  entirely  disappeared  by  the  end  of  the 
second  quarter  of  1871.  Isolated  outbreaks,  traceable  in  almost  every  in- 
stance to  the  epidemics  in  New  York  and  Philadelphia,  occurred  during 
the  same  period  in  Boston  and  in  Washington,  D.  C,  and  at  several  in- 
termediate points. 

Relapsing  fever  in  all  the  great  epidemics  has  been  associated  with 
typhus.  As  a  general  rule,  the  former  disease  has  supplied  the  greater 
proportionate  number  of  cases  at  the  beginning  or  in  the  early  part  of 
the  epidemics,  and  has  gradually  disappeared  till,  toward  the  close  of  the 
epidemic,  typhus  alone  prevailed. 

'  Meredith  Clymer,  M.D.:  Notes  on  the  History  of  Relapsing  Fever.  New  York 
Med.  Jour.,  March,  1870. 

-  Relapsing  Fever  and  Ophthalmitis  Post-febrilis  in  New  York.  Bj  A.  Dubois, 
M.D. ,  Trans.  Amer.  Med.  Assoc,  1848. 

*  Clinical  Reports  on  Continued  Fever,  Based  on  an  Analysis  of  One  Hundred  and 
Fifty-two  Cases.     Buffalo,  1853. 

*  Observations  on  Relapsing  Fever,  as  it  occurred  in  Philadelphia  in  the  Winter  of 
18G9  and  1870.     By  John  S.  Parry,  M.D.     Amer.  Jour.  Med.  Sciences,  Oct.,  1870. 

^  On  Relapsing  Fever  :  A  Lecture  by  Prof.  Austin  Flint,  M.D.  New  York  Me  J. 
Joum.,  March,  1870. 


I 


RELAPSING    FEVER.  309 

Etiology. 

I.  PREDISPOSINa   CAUSES. 

Climate  has  no  direct  influence  upon  the  development  or  propagation 
of  relapsing  fever.  It  has  been  observed  in  India  and  in  Egypt,  as  in  Mos- 
cow, St.  Petersburg,  and  in  Siberia,  upon  the  continent  of  Europe,  as  in 
the  insular  climate  of  Great  Britain.  Nevertheless,  the  disease  has  oc- 
curred most  frequently  and  has  prevailed  most  fiercely,  since  the  time  of 
its  recognition  as  a  distinct  affection,  within  certain  restricted  geographi- 
cal limits.  These  boundaries  include  the  British  Islands,  amono-  which 
Ireland  stands  forth  prominent  as  the  seat  of  origin  of  by  far  the  greater 
number  of  the  epidemics  which  have  invaded  the  sister  isles. 

llie  season  of  the  year  has  little  or  no  inflence  upon  the  epidemic 
prevalence  of  relapsing  fever.  Epidemics  arise,  advance  and  subside, 
uninfluenced  by  the  season.  In  widespread  visitations  of  the  disease  it 
has  broken  out  in  one  place  at  one  time  of  the  year,  at  anothjr  a  little 
later,  and  still  later  at  a  third,  while  it  has  reached  its  maximum  and 
has  declined  at  the  different  places  at  different  periods  of  the  year,  and  to 
all  appearances  wholly  uninfluenced  by  them. 

Relapsing  fever  has  also  prevailed  in  seasons  remarkable  for  the 
amount  of  rain,  and  in  seasons  of  prolonged  drought. 

Age  acts  as  a  predisposing  cause,  seeing  that  the  disease  is  very  fre- 
quent in  childhood — one-third  of  all  the  cases — and  that,  after  the  early 
periods  of  life,  the  greatest  number  of  cases — in  fact,  more  than  one-fourth 
of  all  cases — occur  between  the  twentieth  and  thirtieth  years.  From  thirty- 
five  to  fifty,  the  liability  rapidly  declines,  and  after  fifty  relapsing  fever  is 
comparatively  rare,  although  it  cannot  be  said  that  the  liability  ceases. 
Of  2,111  cases  received  into  the  London  Fever  Hospital  in  twenty-three 
years  (1848-70),  according  to  Dr.  Murchison,  114  males  and  81  females — 
in  all  195,  were  beyond  fifty  years  of  age. 

Sex  cannot  be  said  to  exert  any  direct  influence.  Statistics  of  10,333 
cases  derived  from  various  sources,  and  tabulated  with  reference  to  sex  by 
the  author  last  named,  show  6,175  males  and  4,158  females.  This  differ- 
ence is  to  be  attributed  to  the  fact  that  males  constitute  by  far  the  largest 
proportion  of  the  vagabond  classes,  from  which  are  chiefly  derived  the 
cases  of  relapsing  fever  which  form  the  basis  of  hospital  statistics. 

Occupation  and  'mode  of  life. — No  occupation  predisposes  to  relapsing 
fever,  nor  does  any  in  itself  confer  immunity  from  it.  As  in  the  case  of 
other  directly  contagious  diseases,  nurses  and  other  attendants  upon  the 
sick,  including  medical  men,  are  exposed  to  the  constant  danger  of  con- 
tracting the  disease.  It  has  been  a  common  observation  that  in  all  epi- 
demics a  large  proportion  of  the  cases  admitted  to  the  hospitals  have 
been  wandering  musicians,  peddlers,  beggars,  and  tramps. 


310  THE  CONTINUED  FEVERS. 

The  mode  of  life  and  the  social  condition  of  the  individual  exert,  be- 
yond all  question,  a  powerful  influence.  Destitution,  filth  and  over- 
crowding are  strong  predisposing  causes  of  relapsing  as  well  as  of  typhus 
fever.  These  conditions  not  only  favor  their  outbreak,  but  they  also  con- 
duce in  the  highest  degree  to  their  spreading.  All  accounts  of  epidemics 
of  both  these  diseases  state  that  they  have  arisen  among,  and  have  been 
for  the  most  part  confined  to,  the  poorest  of  the  population  and  to  the 
most  crowded  districts  of  great  cities.  In  the  instances  where  persons 
living  in  affluence  have  been  attacked,  by  reason  of  the  contagious  char- 
acter of  the  fevers,  the  spread  of  the  diseases  among  them  has  been 
limited.  Epidemics  have  in  no  case  arisen  among  the  better  classes  of 
society.  With  very  few  exceptions,  Irish  writers  insist  upon  the  connec- 
tion which  exists  between  fever  and  famine.  Failure  of  the  crops,  or 
want  of  food  depending  upon  lack  of  money  to  buy  it — a  state  of  artifi- 
cial famine — has  preceded  almost  every  epidemic  of  relapsing  fever.  As 
has  been  already  stated,  many  cases  were  observed  during  the  great  fever- 
epidemics  which  attended  the  closing  years  of  the  last  and  the  first  years 
of  the  present  century,  in  which  the  symptoms  closely  corresponded  with 
relapsing  fever.  This  veas  a  period  of  great  want.  Before  the  outbreak 
of  the  epidemic  of  1817,  the  inhabitants  of  Ireland  had  been  in  a  state  of 
extreme  starvation,  due  to  a  succession  of  bad  harvests  and  other  causes. 
The  Scotch  epidemic  of  1843  was  not  preceded  by  failure  of  the  crops; 
yet  the  condition  of  the  poor  was  deplorable,  and  had  been  for  some 
years  the  subject  of  appeals  to  the  authorities.  Murchison  states  that  be- 
tween 1840  and  1843,  four  public  subscriptions,  amounting  to  twenty 
thousand  pounds  sterling,  had  been  raised  in  Edinburgh  alone  to  relieve 
their  pressing  necessities.  Upon  the  appearance  of  the  fever  the  poor 
alone  suffered.  It  is  stated  that  of  the  poor  scarcely  a  single  person 
escaped,  while  some  of  the  medical  men  practising  among  the  better 
classes  did  not  meet  with  a  case.  The  epidemic  of  1847  made  its  appear- 
ance at  a  time  of  extreme  destitution  and  misery  among  the  lower  classes 
of  Great  Britain  and  Ireland;  and  the  appearance  of  relapsing  fever  in 
Silesia  in  the  same  year  followed  upon  a  succession  of  three  bad  harvests, 
which  had  brought  the  inhabitants  to  such  want  that  numbers  died  of 
starvation  alone.  The  epidemic  of  1864—65  in  Russia  was  restricted  to  the 
poorest  and  most  destitute  of  the  people,  and  occurred  at  a  time  when 
provisions  of  all  kinds  were  high  in  price  and  of  poor  quality. 

The  foregoing  facts  form  the  basis  of  the  opinion  long  entertained 
that  scarcity  of  food  is  the  exciting  cause,  or  one  of  the  exciting  causes 
of  relapsing  fever.  This  opinion  was  generally  held  by  the  earlier  writers 
upon  the  subject,  and  has  been,  in  recent  years,  most  ably  and  learnedly 
advocated  by  Murchison.  It  is  certainly  in  accord  with  the  general 
statement  that  no  great  epidemic  has  ever  arisen  among  a  well-fed  popu- 
lace, nor  spread  to  any  great  extent  among  the  prosperous  classes  of  an 


EELAPSINQ   FEVEE.  311 

infected  locality,  and  it  appears  to  explain  the  apparently  independent 
origin  of  the  fever  after  the  lapse  of  years  and  at  distant  points. 

Against  it  are,  however,  arrayed  the  following  facts  : 

Persons  are  constantly,  and  communities  occasionally,  exposed  to  great 
want  without  fever  resulting. 

When  the  disease  attacks  the  well-nourished,  it  runs  a  similar  course 
and  presents  the  same  symptoms  that  characterize  it  among  the  desti- 
tute. 

There  is  no  direct  evidence  to  show  that  starvation  either  occasions 
the  symptoms  of  relapsing  fever,  or  that  it  gives  rise  to  any  infecting 
principle  capable  of  producing  this  or  any  other  specific  fever  in  the  starv- 
ing individual,  or  in  those  brought  in  contact  with  him. 

Epidemics  have  prevailed  among  the  poorer  classes  in  communities 
where  no  general  scarcity  of  food  existed. 

Lebert '  states  that  the  theory  that  looks  upon  relapsing  fever  as  a  fam- 
ine fever  is  not  borne  out  by  the  various  epidemics  that  have  occurred  at 
Breslau,  nor  by  the  aspect  of  the  relapsing  fever  patients  he  examined, 
who  presented  on  an  average  a  well-nourished  appearance.  Parry  writes 
that  the  patients  whom  he  saw  in  the  outbreak  in  Philadelphia  in  1869- 
70,  appeared  to  be,  with  a  single  exception,  well-fed,  and  were  even  fat, 
and  that  all  his  patients  were  able  to  obtain  a  plentiful  supply  of  milk, 
meat,  eggs,  or  any  other  article  of  diet  that  was  ordered.  The  cases  did 
not  occur  among  the  unemployed  and  vagrant,  but  in  the  families  of  those 
■who  held  positions  in  the  neighboring  stores  and  factories,  and  many  of 
whom  had  been  so  employed  for  years.  At  the  time  that  the  disease 
made  its  appearance  wages  were  high,  the  crops  had  been  abundant, 
breadstuffs  were  cheap,  and  potatoes  were  plenty.  He  attributed  the  dis- 
ease to  overcrowding  and  the  "  notoriously  small  breathing-space  allotted 
to  each  individual  in  the  houses  of  the  poor,"  and  refers  to  the  observa- 
tions of  Muirhead,'  who  advances  the  same  view  and  denies  the  potency 
of  starvation  as  the  cause  of  the  fever.  Dr.  Bennett '  states  "  that  he  had 
charge  of  the  Fever  Hospital  in  1846,  where  relapsing  fever  largely  pre- 
vailed, and  he  could  say  that  in  not  one  case  had  it  been  traceable  to 
starvation." 

Finally,  the  discovery  by  Obermeier,*  in  1873,  of  minute  organisms  in 
the  blood  of  relapsing  fever  patients,  points  to  the  nature  of  the  morbific 
principle  which  is  the  exciting  cause  of  the  disease. 

'  Ziemssen's  Cyclopaedia.    Vol.  i.    Article  on  Relapsing  Fever. 

'  Relapsing  Fever  in  Edinburgh.  By  C.  Muirhead,  M.D.:  Edin.  Med.  Joum.,  July, 
1870. 

'  Edin.  Med.  Joum.,  Aug.,  1870. 

*  Dr.  Otto  Obermeier :  Vorkommen  feinster,  eine  Eigenbewegung  Faden  im 
Blute  von  Recnrrenskranken.  Centralblatt  f  iir  die  Med.  "Wissensch. ,  No.  10,  Marz.  1, 
1873. 


312  THE  CONTINUED  FEVERS. 

Before  taking  up  the  special  consideration  of  the  exciting  cause,  we 
must  state  our  view  that,  whatever  may  be  the  form  which  that  cause 
assumes  outside  of  the  human  body,  whatever  its  mode  of  preservation  and 
of  conveyance  from  person  to  person  and  from  place  to  place,  it  finds  in 
the  bodies  of  the  destitute  and  famished  the  most  favorable  circumstances 
for  its  lodgement  and  development,  and  in  the  neglect  of  personal  hygi- 
ene and  the  foul  overcrowding  begotten  of  destitution,  the  most  favora- 
ble conditions  for  its  rapid  dissemination,  and  that  destitution  is,  there- 
fore, the  most  powerful  of  the  predisposing  causes  of  the  disease. 

n.  THE  ExcrriNG  cause. 

Relapsing  fever  is  due  to  an  infecting  principle  communicable  from 
the  sick  to  the  well,  either  directly  or  indirectly,  by  means  of  the  atmos- 
phere, various  fluids,  and  even  solid  substances.  The  nature  of  this  poi- 
son is  no  longer  unknown.  Obermeier's  discovery  of  minute  spiral  fila- 
ments in  the  blood  of  relapsing  fever  patients  threw  a  flood  of  light  upon 
this  subject.  Since  the  date  of  that  observation,  Lebert  and  his  assist- 
ants, Weigert  and  Buchwald,  have  found,  by  systematic  examination  of 
the  blood  of  relapsing  fever  cases,  that  these  protomycetes  are  never  ab- 
sent during  the  initial  febrile  paroxysm  nor  in  the  relapse,  although  they 
diminish  very  rapidly  in  numbers  after  defervescence.  They  have  been 
repeatedly  observed  and  described  by  other  microscopists,  and  quite  re- 
cently Paul  Guttman,'  upon  examination  of  the  blood  of  280  cases  of 
relapsing  fever,  found  them  in  every  case  during  the  period  of  the  fever. 
He  states  that  the  numbers  of  the  characteristic  "  spirilli "  of  Obermeier 
were  not  always  proportionate  to  the  intensity  of  the  attack  nor  the  ele- 
vation of  the  temperature,  that  they  were  sometimes  abundant  in  cases 
attended  by  moderate  rise  in  temperature,  and  rare  where  the  rise  was 
great.  They  were  not  seen,  upon  repeated  examinations  of  the  blood,  dur- 
ing the  period  of  apyrexia;  and  it  is  of  interest  to  note  that,  when  in  the 
intermission  the  temperature  rose  in  consequence  of  a  complication — as, 
for  example,  pneumonia,  spirilli  were  absent.  He  regards  their  parasitic 
nature  as  established  beyond  question.  What  becomes  of  the  spirilli  in 
the  blood  of  the  apyretic  period  is  not  known.  No  trace  of  their  remains 
is  discoverable.  Guttman  regards  their  rapid  disappearance  as  the  more 
remarkable  in  view  of  the  facts  that  they  can  be  preserved  as  microscopic 
]:>reparations  for  a  long  time  (nine  months  or  longer),  and  that  they  may 
be  recognized  in  the  blood  thirty-six  hours  after  death.  Up  to  the  pres- 
ent time  all  attempts  to  cultivate  the  spirilli  outside  the  human  body 
have  been  unsuccessful. 

Dr.  Guttman  also  describes  very  minute  moving  corpuscles,  which  arc 

'  Zur  Histologie  des  Blutes  bei  Febris  Recurrens.     Virchow's  Archiv,  LXXX. ,  1880. . 


RELAPSING    FEVEE.  313 

found  in  the  blood  of  relapsing  fever  patients  both  during  and  between 
the  paroxysms,  but  in  rather  greater  numbers  during  the  febrile  periods. 
They  are  from  one-thirtieth  to  one-twentieth  the  size  of  a  red  corpuscle, 
and  of  a  round  or  oval  shape.  They  are  not  peculiar  to  the  blood  of  re- 
lapsing fever,  but  occur  also  in  that  of  patients  suffering  from  other 
acute  febrile  diseases,  as  pneumonia,  scarlet  fever,  measles,  enteric  fever, 
typhus,  dij^litheria,  and  erysipelas,  and  in  smaller  numbers  even  in  the 
blood  of  persons  in  health.  They  were  successfully  cultivated  in  Pas- 
teur's fluid,  and  appear  to  be  micro-organisms  (mikroparasiten)  derived 
from  the  atmosphere. 

Lebert  describes  the  spirilli  as  follows:  "They  are  exceedingly  slen- 
der, never  exceeding  in  diameter  0.001  mm.,  and  in  length,  0.15  to  0.2 
mm.  Their  form  is  spiral.  In  their  interior  I  have  been  unable  to  make 
out  either  fat-particles,  sheaths,  or  structure  of  any  kind.  Their  motion 
is  very  lively,  rotary,  twisting  and  rapidly  progressive,  but  soon  ceases 

under  the   ordinary  conditions    of   microscopic  examination 

Thus  far  we  have  sought  in  vain  for  this  organism  in  the  secretions  and 
excretions,  as  well  as  in  the  internal  organs;  it  is  probable,  however,  that 
in  the  future  it  may  also  be  found  in  these  localities." 

Up  to  the  present  time  this  variety  of  protoniycetes  has  never  been 
found  in  any  other  disease. 

The  conclusion  that  this  parasite  has  to  do  with  the  causation  and 
development  of  relapsing  fever  is  inevitable.  It  constitutes  the  conta- 
gium.  These  spiral  filaments,  communicated  from  individual  to  individ- 
ual, spread  the  disease.  Finding  in  the  human  body  the  conditions 
favorable  to  their  development,  they  multiply  indefinitely.  The  functional 
perturbations  to  which  their  presence  gives  rise  constitute  the  phenomena 
of  the  fever.  It  is  probable  that,  under  favorable  circumstances  outside 
the  body,  their  existence  may  be  prolonged  through  a  considerable  length 
of  time.  This  existence  may  be  latent,  yet  capable  of  assuming  the  most 
energetic  activity  when  introduced  into  the  human  body.  Such  being 
the  case,  the  possibility  of  transmission  to  remote  points  follows,  and  the 
rise  of  epidemics  at  considerable  intervals  of  time  and  at  points  far  dis- 
tant from  each  other  is  comprehensible  without  the  assumption  of  the 
independent  origin  of  the  germs  of  disease,  or  the  new  development  of  an 
old  poison.  It  is  much  more  in  accordance  with  the  general  laws  of  or- 
ganic development  to  accept  a  continuous  concealed  existence  of  the 
germs,  than  to  have  recourse  to  spontaneous  generation  to  account  for 
their  development  (Lebert). 

The  origin  of  an  epidemic  is  due  to  the  importation  of  the  materies 
morbi  in  the  person  and  belongings  of  a  patient,  or  in  other  materials  from 
an  infected  localitv,  or  else  to  circumstances  calling  into  activity  germs 
that  have  maintained  a  latent  and  harmless  existence  during  a  more  or 
less  extended  lapse  of  time.     The  history  of  relapsing  fever  in  all  great 


314  THE  CONTINUED  FEVERS. 

epidemics  points  to  scarcity  of  food  and  its  attendant  evils  as  the  condi- 
tions favoring  the  activity  of  relapsing  fever  germs. 

When  the  disease  has  appeared  in  any  locality  it  spreads  with  great 
rapidity  by  contagion,  but  in  every  community  it  forms  centres  of  great- 
est prevalence.  These  foci  are  determined  by  the  dense  crowding  to- 
gether of  the  poor  in  the  most  wretched  quarters  of  cities,  and  by  impure 
drinking-water  and  stagnant  water  in  the  neighborhood  of  dwelling- 
houses. 

The  rapidity  of  the  spread  of  relapsing  fever  in  single  houses,  or  within 
limited  districts,  is  in  proportion  to  the  number  of  the  inhabitants  and 
the  amount  of  intercourse  between  the  sick  and  those  surrounding  them. 
It  has  been  a  matter  of  common  observation  that  when  the  disease  has 
made  its  appearance  in  a  house  inhabited  by  several  families,  the  occu- 
pants of  one  apartment  have  been  seized  one  after  another,  or  nearly  at 
tlie  same  time,  that  those  dwelling  upon  the  same  floor  have  been  next 
attacked,  and  afterward  the  neighbors  upon  the  other  floors  in  the  order 
of  the  intimacy  of  the  intercourse  between  families.  Reid,*  of  Glasgow, 
has  placed  upon  record  two  observations  which  illustrate  the  above  state- 
ment. The  first  is  the  account  of  the  introduction  and  spread  of  the 
disease  at  the  Dalmarnock  colliery  in  1843. 

The  colliers,  comprising  forty  different  families,  occupied  a  large  tenement  standing 
alone  in  the  midst  of  open  fields.  It  consisted  of  three  stories,  entered  by  three  sepa- 
rate stairways.  In  May  an  Irish  family  took  possession  of  a  single  apartment  on  the 
uppermost  story,  the  youngest  child  being  at  the  time  sick  of  the  fever.  On  the  sec- 
ond of  June  the  father  sickened,  and  afterward  successively  every  member  of  the  fam- 
ily. The  fever  then  spread  from  room  to  room,  and  in  the  space  of  two  months 
attacked  twenty-two  persons  on  this  story,  the  other  inhabitants  remaining  all  this 
time  exempt. 

In  the  second  instance  the  disease  was  introduced  from  a  neighboring  village  into 
a  house  of  two  apartments  occupied  by  eleven  persons.  All  of  these  were  attacked, 
and  every  one  suffered  the  relapse  ;  but  in  the  adjoining  house,  with  a  similar  entry 
and  separated  only  by  a  brick  partition,  where  the  occupants  were  nearly  equally  nu- 
merous, and  from  their  circumstances  and  habits  equally  susceptible,  all  escaped. 

In  this  connection  it  is  proper  to  call  the  attention  of  the  reader  to  the 
statement  already  made,  that  the  attendants  upon  the  sick  are  very  liable 
to  contract  the  disease.  This  liability  increases  in  proportion  to  the 
closeness  of  the  association  between  the  attendant  and  the  patients,  re- 
quired by  the  duties  of  the  former.  Thus,  male  and  female  nurses,  and  the 
resident  physicians  in  hospitals,  are  much  more  frequently  attacked  than 
the  visiting  physicians.  In  fact,  in  general  hospitals  it  is  only  those  who 
are  brought  into  close  relation  with  relapsing  fever   cases,  or  who  wash 

'  The  New  Form  of  Fever  at  present  Prevalent  in  Scotland.  By  W.  Reid,  M.D., 
London  Medical  Gazette,  vol.  xxxiii ,  1843. 


BELAPSING   FEVER.  315 

their  clothes  or  bedding,  that  contract  the  disease.  Nurses  in  the  medi- 
cal wards  into  which  fever  cases  are  not  admitted,  and  those  in  the  surgi- 
cal wards,  as  a  rule  escape. 

My  colleague,  Dr.  Morris  Longstreth,  at  the  time  when,  as  residents 
in  the  Pennsylvania  Hospital,  we  had  the  opportunity  of  observing  re- 
lapsing fever  in  the  wards  during  the  epidemic  of  18G9-71,  contracted 
the  disease.  The  records  of  every  epidemic  abound  in  instances  of  the 
communication  of  the  fever  from  patients  to  their  attendants.  Dr.  Welsh' 
wrote  in  1819,  as  follows:  "  When  acting  as  clerk  to  Dr.  Hamilton,  in  the 
Royal  Infirmary,  in  the  course  of  four  months  my  three  colleagues,  two 
of  the  young  men  in  the  apothecary's  shop,  two  housemaids  and  thirteen 
or  fourteen  nurses,  caught  the  disease,  and  the  matron  and  one  of  the 
dressers  died  of  it.  Since  I  left  the  infirmary,  three  more  of  the  gentlemen 
acting  as  clerks,  one  of  the  young  men  in  the  shop,  and  many  more  of 
the  nurses,  have  caught  the  infection,  but  the  number  I  do  not  know. 
Since  Queensbury  House  was  opened,  on  February  23,  1818,  my  friends, 
Messrs.  Stephenson  and  Christison,  the  matron,  two  apothecaries  in  suc- 
cession, the  shop-boy,  washer-woman  and  thirty-eight  nurses,  have  been 
infected;  four  of  the  nurses  have  died.  With  the  exception  of  two  or 
three  nurses,  who  have  been  but  a  short  time  in  the  hospital,  I  am  now 
the  only  person  in  this  house  who  has  not  caught  the  disease  within  the 
last  eight  or  ten  months.  Several  students,  whom  curiosity  led  too  near 
the  persons  of  the  patients,  might  be  adduced  as  additional  evidence. 
When  it  begins  in  a  family,  we  always  expect  more  than  one  of  them  to 
be  affected.  I  could  mention  instances  of  four,  five,  six  and  seven  being 
sent  to  the  hospital  out  of  one  family;  eight,  nine  and  ten  out  of  one 
room;  twenty  and  thirty  out  of  one  stair;  and  thirty  and  forty  out  of  one 
close;  and  this  all  in  the  course  of  a  few  months."  Writing  of  the  fever 
of  1843-44,  Dr.  Wardell "  states  that  "  most  of  the  medical  officers  con- 
nected with  the  Edinburgh  Royal  Infirmary  and  additional  fever  hospitals 
were  seized  with  it;  eight  of  the  resident  and  clinical  clerks  in  quick  suc- 
cession became  aftected,  and  out  of  that  number  no  less  than  six  were 
yellow  cases,  and  thus  obviously  in  danger  of  their  lives.  The  majority 
of  the  nurses  and  domestics  took  the  disease,  and  of  the  former,  at  one 
time  no  less  than  nineteen  were  laboring  under  it.  Some  of  the  dispens- 
ing physicians  and  other  practitioners  took  the  disorder,  as  also  several 
of  the  clergy  and  visitors  of  the  sick,  whose  duties  brought  them  to  the 
bedsides  of  the  patients.  The  few  cases  occurring  among  the  higher 
classes  resident  in   the  new  town  were  generally  to  be  traced   to  the  in- 


'  A  Practical  Treatise  on  the  Effiracy  of  Bloodletting  in  the  Epidemic  Fever  of 
Edinburgh,  illustrated  by  Numerous  Cases  and  Tables,  extracted  from  the  Journals  of 
the  Queensbury  House  Fever  Hospital.     By  Benjamin  Welsh,  M.  D.     Edinburgh,  1819. 

*  The  Scotch  Epidemic  Fever  of  1843-44.  London  Medical  Gazette,  xxxvL-xl. 
1&46-47. 


31G  THE    CONTINUED    FEVERS. 

lluence  of  contagion,  the  parties  affected  having  had  either  immediate  or 
indirect  coniinunication  with  th'ose  sufEering  under  the  disease."  Cor- 
mack,'  in  his  account  of  the  same  epidemic  observed:  "Almost  all  the 
clerks  and  others  exposed  to  the  contagion  have  been  seized.  Dr.  Heude, 
and  his  successor  Mr.  Reid,  in  the  ISew  Fever  Hospital,  Dr.  Bennett,  my 
successor  there,  Mr.  Cameron  and  his  successor,  Mr.  Balfour,  in  the  adjoin- 
ing fever-house,  as  well  as  most  of  the  resident  and  clinical  clerks  in  the 
Royal  Infirmary,  have  gone  through  severe  attacks  during  the  past  summer 
and  autumn.  Hardly  any  of  the  nurses,  laundry-women,  or  others  com- 
ing in  contact  either  with  the  patients  or  their  clothes,  have  escaped;  at 
one  time  there  were  eighteen  nurses  off  duty  from  the  fever;  and  of  those 
who  have  recently  been  engaged  for  the  first  time,  or  of  those  who  have 
hitherto  escaped,  one  and  another  is  from  time  to  time  being  laid  up." 
Murchison  informs  us  that,  "  in  the  London  Fever  Hospital,  during  the 
years  1869-70,  twenty-seven  of  the  nurses  and  officers,  and  five  patients 
contracted  relapsing  fever.  One  nurse,  who  had  been  in  the  hospital  for 
nearly  twenty  years,  and  had  passed  through  typhus,  had  a  severe  attack 
of  relapsing  fever  shortly  after  the  first  cases  of  the  disease  were  ad- 
mitted." 

Persons  in  health,  from  localities  where  the  disease  is  unknown,  are 
attacked  upon  coming  in  contact  with  the  sick  in  an  infected  community 
at  a  distance.  The  pestilential  centres  of  relapsing  fever  are  in  all  in- 
stances limited  to  the  quarters  of  cities  and  like  districts  inhabited  by 
the  poor,  while  persons  living  in  easy  circumstances  and  in  opulent 
neighborhoods,  under  favorable  conditions  of  public  and  personal  hygiene, 
as  a  rule  wholly  escape.  This  immunity  ceases,  however,  upon  their  vis- 
iting the  sick.  On  the  other  hand,  relapsing  fever  is,  in  every  epidemic, 
liable  to  be  imported  by  infected  persons  into  localities  before  exempt. 

The  history  of  the  march  of  the  disease  in  the  epidemics  of  Great 
Britain  sufficiently  illustrate  this  statement.  It  is  also  stated  that  it  was 
carried  in  this  way  from  St.  Petersburg  to  other  cities  in  Russia,  and  most 
writers  are  agreed  that  the  American  outbreaks  were  due  to  importation 
from  the  other  shores  of  the  Atlantic,  although  it  was  not  possible  to  trace 
its  route.  It  is  certain,  however,  that  in  several  of  the  local  epidemics  out- 
side of  Philadelphia  and  New  York  the  disease  was  brought  from  those 
cities  by  persons  who  had  been  in  contact  with  the  sick. 

The  following  striking  example  of  the  contagion  is  narrated  by 
Parry : 

"  A  man  left  Philadelphia  about  February  1st.  remaining  for  two  months  in  West- 
em  Pennsylvania.  During  his  absence  his  health  was  good,  and  he  had  no  known 
opportunity  to  take  any  disease.     On  returning  home  he  spent  several  days  with  a 


'  Natural  History,  Pathology  and  Treatment  of  the  Epidemic  Fever  at  present  pre- 
vailing in  Edinburgh  and  other  Towns.     By  J.  Rose  Cormack,  M.D.     London,  1843. 


RELAPSING    FEVER.  317 

friend  in  the.  second  paroxysm  of  relapsing  fever.  He  then  went  to  his  brother's, 
and  ten  days  after  reaching  the  city  was  seized  with  mild  relapsing  fever,  and  was 
sick  five  days.  In  about  two  weeks  his  brother's  wife  was  taken  and  had  it  se- 
verely. Subsequently  another  case  occurred  in  the  same  family.  During  the  re- 
mission this  same  man  went  to  his  brother-in-law's  in  a  distant  portion  of  the  city. 
Here  he  had  the  relapse,  which  lasted  four  days.  This  family  consisted  of  six  per- 
sons, four  of  whom  were  children.  Only  one  of  the  six,  the  mother,  escaped.  It  ia 
worthy  of  note  that  the  youngest  children,  who  were  most  exposed  by  being  with 
their  uncle,  and  who  were  aged  respectively  four  and  six  years,  were  taken  first  on, 
the  eleventh  and  twelfth  days  after  their  relative  reached  the  house.  The  older  ones, 
who  were  nearly  grown  up  and  engaged  at  work  during  the  day,  did  not  take  sick 
until  the  younger  ones  were  in  the  relapse." 

Ill  hospitals  the  nurses  and  attendants  have  never  contracted  the  dis- 
ease until  after  the  admission  of  relapsing  fever  patients. 

Without  doubt  it  is  in  many  instances  communicated  from  the  sick  to 
the  well  by  direct  contagion,  that  is,  by  actual  contact.  Hence,  it  spreads 
rapidly  in  chambers  and  iiouses  occupied  by  large  numbers  of  destitute 
persons,  and  in  the  lodging-houses  frequented  by  the  vagabond  poor. 

But  it  is  also  largely  communicated  by  fomites.  In  this  way  only  can 
be  explained  the  great  liability  of  the  laundry- women  in  hospitals  to  con- 
tract the  disease  without  direct  contact  with  the  sick,  and  under  circum- 
stances that  render  it  in  the  highest  degree  improbable  that  the  poison 
reaches  them  either  by  means  of  the  atmosphere  or  of  drinking-water. 
Parry  relates  the  following  instances  in  which  relapsing  fever  was  trans- 
ported to  a  distance  by  infected  clothing: 

"  A  family  lived  in  a  healthy  neighborhood  and  were  in  comfortablG  circumstances. 
One  of  the  eons  was  employed  in  a  factory,  where  they  procured  a  new  hand,  who,  it 
was  afterward  learned,  had  just  left  a  hospital  where  he  had  been  ill  with  relapsing 
fever.  From  him  the  son  purchased  a  pair  of  overalls  and  carried  them  home.  On 
April  19  th  one  of  the  sisters  washed  them.  She  was  taken  ill  with  the  fever  on  May 
Ist.  At  the  same  time  this  garment  was  handled  by  two  other  sisters,  who  fell  sick 
on  the  2d  and  3d  of  May,  respectively." 

"  A  woman  learned  through  the  newspapers  that  her  husband  had  been  picked  up 
ill  in  the  street  and  taken  to  the  Philadelphia  Hospital.  He  had  not  been  home  for 
some  time  before.  On  March  21st  or  22d  she  sent  a  friend  to  the  hospital  to  learn 
his  condition.  She  found  him  dead,  it  was  stated,  from  relapsing  fever.  She  went 
to  the  dead-room  and  identified  his  body,  which  was  not  brought  away  for  burial. 
She  carried  his  clothing  to  her  own  home  and  placed  it  in  a  room  next  to  her  chil- 
dren's bed-room,  with  an  open  door  between  them.  Four  cases  of  the  disease  afterward 
occurred  in  the  family.  On  April  7th,  a  boy  was  taken,  April  25th  a  girl,  April  29th 
another  girl,  and  on  May  3d  her  husband.  There  had  certainly  been  no  cases  in  the 
immediate  neighborhood  before  that  time." 

It  is  in  the  highest  degree  probable  that  the  disease  can  be  communi- 
cated by  means  of  the  atmosphere.  But  the  distance  to  which  the  poison 
can  be  transported  in  this  way  in  sufficient  concentration  to  produce  the 


318  THE  CONTINUED  FEVERS. 

disease  cannot  be  very  great.  Those  only  who  are  in  close  communica- 
tion with  the  sick,  or  who  visit  them  in  their  ill-ventilated  quarters,  or 
who  reside  near  at  hand,  suffer.  With  free  ventilation  the  disease  almost 
ceases  to  be  communicable  (Murchison).  Lebert  deems  it  worthy  of  re- 
mark that  in  all  epidemics  occurring  in  his  wards,  in  which  thorough 
ventilation  is  maintained  summer  and  wdnter,  cases  of  contagion  have 
been  exceedingly  rare. 

The  danger  of  contracting  the  disease  through  the  atmosphere  appears 
to  increase  with  the  length  of  the  exposure.  In  a  few  instances  the  dis- 
ease has  seemed  to  follow  promptly  upon  exposure.  The  poison  in  these 
cases  must  have  been  very  concentrated.  As  a  rule,  the  resident  physi- 
cians in  hospitals  are  more  apt  to  contract  relapsing  fever  than  dispensary 
physicians  who  visit  their  patients  in  their  badly  ventilated  houses,  and, 
remaining  but  a  short  time,  have  constant  opportunities  to  breathe  an  un- 
contaminated  air  in  passing  from  house  to  house.  The  length  of  time 
necessary  to  contract  relapsing  fever  by  exposure  to  the  atmosphere  of 
the  sick-room  without  actual  contact  is  longer  than  in  the  case  of  typhus. 
Finally,  Lebert  ascribes  great  importance  to  drinking-water  as  a  carrier  of 
the  infecting  principle.  The  pathogenetic  protomycetes  thriving  in  it 
may  infect  many  persons  in  the  same  house  at  the  same  time,  or  in  rapid 
succession,  as  is  seen  in  cholera.  The  researches  of  this  observer,  in  1868 
and  1869,  show  that  in  27  per  cent,  the  interval  between  new  cases  in  the 
same  house  was  only  1  day;  in  16  percent.,  2  days;  in  11  per  cent.,  3; 
in  5  per  cent.,  4;  in  something  over  6  per  cent.,  5;  in  6  per  cent.,  6;  and 
in  4  per  cent.,  T  days.  In  other  words,  75  per  cent,  occurred  within  the 
first  week,  and  54  per  cent,  within  the  first  three  days.  It  follows  from 
these  figures,  he  adds,  that  too  much  stress  must  not  be  laid  upon  the 
transmission  of  the  disease  from  individual  to  individual  by  direct  con- 
tagion, and  he  regards  the  simultaneous  or  nearly  simultaneous  infection 
of  several  persons  by  means  of  drinking-water  as  the  most  probable  expla- 
nation of  the  facts.  He  informs  us  that  the  nidus  of  typhus  and  relapsing 
fever  in  Breslau  was  in  a  quarter  of  the  city  supplied  by  such  impure 
drinking-water  that  a  whole  fauna  and  flora  might  be  found  in  it. 

TTie  period  of  incubation  of  relapsing  fever  is  variable.  In  some  rare 
instances  it  has  been  absent,  the  symptoms  following  immediately  upon 
the  first  exposure  to  the  contagion.  According  to  Murchison,  it  varies 
from  five  to  sixteen  days.  Parry  estimates  it  to  be  from  seven  to  fifteen 
days.  Lebert  states  that  it  is  from  five  to  seven  days.  The  number  of 
accurate  observations  bearing  upon  this  point  is  limited. 

Ao  immunity  from  subsequent  attacks  is  experienced  by  those  who 
have  suffered  from  relapsing  fever.  Observers  have  recorded  the  occur- 
rence of  second  and  even  third  attacks  in  the  same  individual,  within  the 
course  of  several  months,  in  almost  all  epidemics.  In  this  respect  relaps- 
ing fever  presents  a  striking  contrast  to  typhus,  and,  in  fact,  to  most  of 


RELAPSING    FEVER.  319 

the  other  infectious  fevers.  Dr.  Christison'  remarks  that,  during  the  epi- 
demic of  1817-19,  he  experienced  no  fewer  than  three  separate  attacks  in 
his  own  person,  within  fifteen  months. 

As  has  been  already  pointed  out,  there  exists  a  remarkable  association 
of  relapsing  fever  with  typhus  in  epidemics.  Prior  to  1843,  the  former 
fever  was  looked  upon  as  a  mild  form  of  the  latter.  To  Dr.  Henderson,' 
of  Edinburgh,  is  due  the  credit  of  having  first  pointed  out  their  essential 
difference.  He  showed  that  they  were  characterized  by  different  symp- 
toms, and  stated  his  belief  that  they  arose  from  different  poisons.  His 
views,  which  were  confirmed  by  many  other  observers  at  that  period  and 
since,  were  based  upon  the  two-fold  proposition  that,  first,  the  one  fever 
under  no  circumstances  gave  rise  by  communication  to  the  other;  and 
secondly,  that  an  attack  of  typhus  never  conferred  immunity  from  relaps- 
ing fever,  any  more  than  the  latter  afforded  protection  from  typhus. 

Henderson  and  others  found  that  only  in  the  rarest  instances,  cases  of 
relapsing  fever  and  of  typhus  fever  occurred  at  the  same  time  in  the 
same  house.  On  the  other  hand,  numerous  excellent  observers  have  re- 
corded instances  of  the  association  of  the  two  fevers  in  the  same  house  and 
even  in  the  same  room.  This  discrepancy  is  to  be  readily  explained  by  the 
manner  in  which  the  two  diseases  are  associated  in  most  epidemics.  In 
circumscribed  localities  there  was  the  same  sequence  of  the  two  fevers  as 
was  found  in  studying  the  history  of  wide-spread  epidemics:  at  first,  relaps- 
ing fever  only;  then  relapsing  fever  and  typhus  together;  and,  last  of  all, 
typhus  alone  (Murchison). 

Cases  in  which  relapsing  fever  follows  upon  typhus  in  the  same  indi- 
vidual are  rare;  but  the  instances  in  which  the  order  of  events  has  been 
reversed,  and  the  latter  has  followed  relapsing  fever  in  the  course  of  a 
few  weeks  or  months,  have  been  so  numerous  as  to  attract  the  attention 
of  most  observers.  Lebert  collected  accurate  statistics  of  fifty-three  cases 
of  relapsing  fever  in  which  an  attack  of  typhus  occurred  at  an  interval  of 
from  several  weeks  to  a  few  months  later.  The  subjects  were  mostly  be- 
tween fifteen  and  sixty  years  of  age.  The  mortality  of  typhus  in  those 
cases  was  7.55  per  cent.,  half  the  death-rate  of  the  other  typhus  cases. 
Whether  this  lowered  death-rate  was  the  result  of  the  chance  association 
of  favorable  cases,  or  of  an  influence  on  the  part  of  the  forerunning  relaps- 
ing fever  poison,  which  rendered  that  of  typhus  less  dangerous,  remains 
unsettled. 

The  peculiar  relationship  of  relapsing  and  typhus  fevers,  both  as  re- 
gards the  individual  and  as  regards  the  community,  point  to  an  affinity 

'  On  the  Changes  whicli  have  Taken  Place  in  the  Constitution  of  Fevers  and  In- 
flammations in  Edinburgh  duriug  the  Last  Forty  Years.  Edia.  Med.  Journ.,  Jan., 
1858. 

-  On  Some  of  the  Characters  which  Distinguish  the  Present  Epidemic  Fever  from 
Typhus.     Edin.  Med.  and  Surg.  Journ.,  vol.  xli.,  1844. 


320  THE  CONTINUED  FEVERS. 

between  them  that,  in  spite  of  their  essential  difference,  cannot  be  acci- 
dental. 

Clinical  History. 

Relapsing  fever  is  divisible  into  four  distinct  stages.  These  are,  in 
ordinary  cases  :  the  primary  paroxysm,  the  intermission,  the  relapse,  and 
*  convalescence. 

The  attack  begins  abruptly — a  prodromic  stage  being,  as  a  rule,  absent. 
If  prodromes  occur  at  all,  they  are  of  short  duration,  and  consist  of  general 
malaise,  dull  pains  in  the  head,  wakefulness,  loss  of  appetite,  and  the  like. 

The  speedy  onset  of  the  disease  is  characteristic.  On  waking  in  the 
morning,  or  in  the  middle  of  the  day  while  engaged  in  their  ordinary 
pursuits,  more  rarely  later  in  the  course  of  the  day,  or  at  night,  the  pa- 
tients are  seized  with  high  fever,  ushered  in  with  a  sense  of  chilliness  in 
about  half  the  cases,  and  with  a  decided  chill  in  a  much  smaller  propor- 
tion of  them.  When  the  disease  begins  with  a  rigor,  it  recurs  in  some 
instances  irregularly  during  the  first  two  or  three  days;  and,  as  sweating 
is  often,  though  by  no  means  in  all  the  cases,  present  during  this  period, 
a  superficial  resemblance  to  the  paroxysms  of  intermittent  fever  may 
arise.  The  sweating  usually  breaks  out  upon  the  face  and  upper  parts  of 
the  body,  while  the  rigor  continues  without  the  intervention  of  a  distinct 
hot  stage. 

In  other  instances  sweating  does  not  occur  till  the  second  or  third 
day,  when  it  may  be  profuse  and  continue  for  several  hours,  without  re- 
lief to  the  headache  or  other  symptoms.  The  skin  is,  during  the  paroxysm, 
frequently  bathed  in  sweat,  while  the  temperature  remains  high.  There 
is  debility  from  the  onset,  and  this,  with  the  giddiness,  headache,  and 
pains  in  the  joints  and  muscles,  compels  the  patient  to  betake  himself  to 
bed  at  once.  In  the  lightest  cases  he  is  able  for  a  time,  or  even  through- 
out the  attack,  to  continue  his  avocation. 

In  a  little  time  after  the  initial  symptom  the  skin  becomes  dry  and 
very  hot  ;  there  is  intense  thirst  and  great  aggravation  of  the  pains  ;  appe- 
tite is  lost,  and  nausea  and  vomiting  are  common,  sometimes  persistent. 
The  vomited  matters  consist  of  a  greenish  fluid.  The  temperature  rises 
rapidly.  The  morning  following  the  onset  it  may  exceed  39° — iO°  C. 
(103.2° — 104°  F.),  and,  assuming  an  irregular  and  faintly  marked  inter- 
mittent type,  it  mounts,  in  the  course  of  a  few  days,  some  degrees  higher — 
4i°— 42°  C.  (105.8°— 107.6°  F.).  The  pulse  is  frequent,  usually  exceeding 
110,  often  120,  and  occasionally  beating  as  often  as  140 — IGO  per  minute. 
The  difference  in  the  frequency  of  the  pulse  in  the  morning  and  in  the 
evening  is  but  slight.  It  is  of  moderate  fulness  and  tension,  often  quick, 
sometimes  dicrotic. 

The  tongue  is  usually  moist,  and  covered  with  a  white  or  yellowish — 


IIELAPSINO    FEVER.  321 

white  fur  of  varying  thickness  ;  it  is  apt  to  continue  thus  coatedthrough- 
out  the  paroxysm  ;  in  a  small  proportion  of  the  cases  it  becomes  dry,  or 
shows  a  dry,  brownish  streak  in  the  middle.  The  bowels  are  constipated, 
or  rarely  there  is  slight  and  somewhat  persistent  intestinal  catarrh. 

In  a  varying  proportion  of  cases,  but  without  great  frequency,  jaun- 
dice appears  during  the  course  of  the  first  paroxysm.  There  is  no  char- 
acteristic eruption  ;  sudamina  appear  late  ;  herpes  facialis  occasionallv 
occurs.  The  skin  is,  as  a  rule,  moist  after  the  first  few  days.  In  many 
cases  it  remains  dry  until  the  crisis. 

As  early  as  the  second  day  a  feeling  of  distress  in  the  upper  part  of 
the  abdomen  is  complained  of.  This  approaches  more  nearly  to  actual 
pain  in  the  left  hypochrondium  than  in  the  right  (Lebert).  Physical  ex- 
amination reveals  enlargement  of  the  liver  and  a  rapidly  progressive  in- 
crease in  the  size  of  the  spleen,  which  not  infrequently  reaches  below  the 
ribs.  There  is  marked  tenderness  in  the  epigastrium  and  in  the  splenic 
and  hepatic  areas. 

At  the  commencement  of  the  attack,  pains  in  the  back  and  joint-pains 
are  marked.  To  these  are  speedily  added  distressing  muscle-pains  in  all 
parts  of  the  body,  as  well  as  in  the  upper  and  lower  extremities — but  most 
severe,  as  a  rule,  in  the  calves  of  the  legs.  These  pains  are  described  by 
the  patients  as  stabbing,  burning,  grinding.  They  are  present  when  the 
body  is  in  repose,  but  are  aggravated  both  by  movement  and  by  pressure. 
After  the  first  days  the  headache  lessens,  but  the  muscular  pains  persist. 
The  patients  lie  motionless  to  avoid  the  increase  of  pain  which  change  of 
position  induces. 

Sleeplessness  is  a  distressing  symptom.  Pain  prevents  sleep.  The 
mind  is  clear.  The  expression  lacks  the  dulness  of  typhus  and  enteric 
fevers  ;   delirium  is  rare. 

Epistaxis  occurs,  but  with  no  great  frequency.  It  is  more  common  iu 
childhood  than  in  adult  life  (Parry). 

The  urine  presents  the  characters  of  febrile  urine  in  general.  It  more- 
over not  infrequently  contains  albumen.  When  jaundice  is  present,  it 
contains  bile-pigment. 

Upon  the  fifth,  sixth,  or  seventh  day,  as  a  rule,  but  sometimes  as  early 
as  the  third,  very  rarely  as  late  as  the  tenth,  the  sickness  apparently 
comes  to  an  abrupt  end.  The  symptoms,  in  some  instances  having  even 
augmented  in  severity,  suddenly  cease.  The  change  is  mostly  attended 
by  a  critical  discharge,  usually  by  a  profuse  sweat,  sometimes  by  diar- 
rhoea, more  rarely  by  bleeding  from  the  nose,  rectum,  or  vagina.  In  rare 
instances  the  crisis  is  preceded  by  a  brief,  violent  delirium.  The  tempera- 
ture, usually  during  the  course  of  the  night,  falls  to  a  point  below  the  nor- 
mal standard,  the  pulse  becomes  much  less  frequent,  the  skin  cool.  The 
breathing,  which  has  been  hurried,  becomes  normal,  the  pains  in  the  muscles, 
and  the  headache  lessen  greatly,  or  cease  altogether.  Thirst  no  longer 
21 


322  THE  CONTINUED  FEVERS. 

torments  the  patient,  the  tongue  cleans,  appetite  returns,  the  liver  de- 
creases in  size,  and  the  spleen  contracts  almost  as  rapidly  as  it  augmented 
in  volume;  epigastric  tenderness  disappears,  and  jaundice,  if  present,  be- 
criiis  to  fade.  To  all  the  evidences  of  a  severe,  even  alarming  illness,  have 
rapidly  supervened  a  condition  of  comfort  and  apparently  almost  com- 
plete convalescence.  But  for  a  feeling  of  weakness,  the  patient  regards 
himself  as  well.  His  strength  augments  from  day  to  day,  and  he  arises 
and  moves  about — often,  if  in  hospital,  insisting  upon  going  to  his  home, 
in  disregard  of  the  warnings  that  he  will  suffer  a  relapse. 

During  the  intermission,  in  most  cases,  the  convalescence  is  rapid  and 
the  patient  in  truth  resumes  the  appearance  of  health.  The  appetite  is 
usually  excellent.  In  many  cases,  however,  there  is  a  notable  slowness  of 
the  pulse — 40  to  G8;  in  not  a  few  the  first  sound  of  the  heart  is"  faint, 
sometimes  almost  inaudible,  while  the  second  is  relatively  intensified. 
Great  muscular  weakness,  and  even  paresis  of  the  lower  extremities,  have 
been  observed  at  this  period. 

The  spirilli  of  Obermeier,  constant  during  the  periods  of  pyrexia,  are 
not  now  found  upon  microscopic  examination. 

The  jDeriod  just  described  usually  lasts  about  a  week.  In  some  in- 
stances it  does  not  exceed  four  or  five  days;  in  others,  it  may  extend  to 
two  weeks,  and  in  very  rare  cases  the  first  paroxysm  has  comprised  the 
whole  of  the  attack,  not  being  followed  at  all  by  a  second  pyretic  period. 

Between  the  twelfth  and  twentieth  days  from  the  beginning  of  the  at- 
tack, but  in  by  far  the  greatest  number  of  cases,  on  or  about  the  four- 
teenth day,  the  patient,  unexpectedly  to  himself  and  with  the  same  sudden- 
ness as  before,  again  falls  ill.  Commonly  in  the  night,  biit  sometimes 
during  the  day,  the  relapse  sets  in.  Its  advent  is  attended  by  chilliness 
or  a  decided  riofor,  or  it  may  be  marked  by  fever  without  either.  The 
symptoms  are  a  repetition  of  those  of  the  primary  paroxysm.  There 
are  the  headache,  the  pains  in  the  back  and  limbs,  the  hot  skin,  the  abrupt 
high  fever,  the  rapid  action  of  the  heart,  the  furred  tongue,  vomiting,  con- 
stipation, tenderness  in  the  epigastric  zone,  that  characterize  the  earlier 
sickness.  The  liver  and  spleen  again  undergo  rapid  augmentation  in 
volume,  and  upon  microscopic  examination  the  spirilli  are  found  in  num- 
bers not  less  than  before.  ^Yith  the  approach  of  convalescence  their  num- 
ber again  diminishes  and  they  finally  disappear. 

It  may  be  stated  that,  as  a  general  rule,  the  symptoms  of  the  relapse 
are  less  severe  than  those  of  the  first  febrile  period;  exceptionally  tiiey 
are  more  so.  The  tvpe  of  the  fever  of  the  second  paroxysm  is  more  dis- 
tinctly remittent  than  that  of  the  first,  marked  remissions  occurring  in 
the  morninof,  decided  exacerbations  toward  niofht. 

The  length  of  the  relapse  is  usually  about  three  days;  it  is  occasionally 
almost  abortive,  not  exceeding  a  day;  at  other  times  it  may  be  extended 
to  five  davs  or  more. 


RELAPSING    FEVEK,  323 

The  second  crisis,  like  the  first,  commonly  sets  in  during-  the  night,  and 
is  attended  by  abundant  sweating  and  a  fall  of  the  temperature  below  the 
normal,  with  a  corresponding  decrease  in  the  frequency  of  the  pulse. 

The  second  defervescence  is  in  some  cases  also  preceded  by  a  brief  but 
marked  intensification  of  all  the  symptoms. 

Occasionally  a  second  relapse,  attended  with  symptoms  similar  to  those 
of  the  first  and  lasting  two  or  three  days,  occurs  on  or  about  the  twenty- 
first  day.  Less  frequently  a  third,  and  still  less  frequently  a  fourth  re- 
lapse, has  been  observed. 

x\t  the  termination  of  the  disease  the  condition  of  the  patient  is  com- 
paratively comfortable.  The  fever  ceases,  the  pains  disappear,  appetite 
is,  in  most  cases,  speedily  regained;  but  the  loss  of  strength  and  the  ema- 
ciation are  such  that  a  number  of  weeks  must  elapse  before  the  sufPei-er 
is  suflSciently  restored  to  health  to  resume  his  ordinary  avocations.  The 
whole  period,  from  the  beginning  of  the  sickness  till  complete  convales- 
cence, is,  upon  an  average,  six  weeks.  Anaimic  murmurs  often  jjei'sist 
for  a  still  longer  period. 

The  death-rate  varies  between  two  and  four  per  cent.,  differing  in  dif- 
ferent epidemics.  Death  may  occur  from  the  intensity  of  the  fever  and 
the  consequent  exhaustion,  usually  at  the  close  of  the  relapse,  or  by  pro- 
gressive exhaustion,  after  several  relapses.  Occasionally  a  sudden  fatal 
termination  takes  place  at  the  crisis,  by  failure  of  the  heart.  Death  is 
due,  in  some  instances,  to  suppression  of  urine,  with  coma  and  convul- 
sions. It  may  also  result  from  pyaemia  following  softening  and  abscesses 
of  the  spleen,  and  the  last-named  lesions  have  by  rupture  caused  fatal 
peritonitis. 

Pregnant  women  almost  invariably  abort  or  miscarry  during  the  course 
of  relapsing  fever.  This  accident  exceptionally  occurs  in  the  first  par- 
oxysm, commonly  in  the  second.  The  foetus,  even  at  the  approach  of  term, 
perishes,  and  the  life  of  the  mother  is  often,  though  not  invariably,  lost. 

Death  is  frequently  the  result  of  this  and  other  complications,  par- 
ticularly pneumonia,  or  of  the  aggravation  of  previously  existing  severe 
disease.  In  relapsing  fever,  as  in  other  epidemic  diseases,  abortive  cases 
are  not  infrequently  encountered.  Cases  of  this  kind  may  terminate  with 
a  single  febrile  paroxysm,  attended  with  symptoms  of  moderate  intensity, 
sometimes  indeed  so  light  as  not  to  compel  the  patient  to  take  to  his  bed, 
or  a  second  paroxysm  of  short  duration  and  little  severity  occurs. 

In  view  of  the  protomycetic  basis  of  the  disease,  it  is  difficult  to  com- 
prehend the  varying  intensity  of  the  attack.  The  numbers  of  spirilli  dis- 
coverable in  the  blood  have  not  always  been  proportionate  to  the  severity 
of  the  symptoms.  There  is,  doubtless,  a  different  degree  of  tolerance  of 
the  presence  of  this  particular  parasite  in  different  individuals.  In  the 
words  of  Lebert,  "  it  is  possible  that,  according  to  the  predisposition,  a 
grave  difference  may  result  as  regards  the  pyrogenetic  products." 


324  THE  CONTINUED  FEVEKS. 

Cormack,'  iu  his  description  of  the  epidemic  of  relapsing  fever  in  1S43, 
referred  the  cases  to  two  general  groups.  Of  these,  the  first  he  called 
the  ordinary  or  moderately  congestive  form.  This  included  the  common, 
mild,  and  average  cases,  which  were  rarely  fatal  except  in  consequence  of 
some  complication.  The  second  he  termed  the  Juyhly  cony estive  form. 
In  tliis  form  a  deep,  persistent,  purple  color  of  the  face,  intense  jaundice, 
marked  enlargement  of  the  liver  and  spleen,  hemorrhages  from  the  mucous 
tracts,  drowsiness,  delirium,  aiid  subsultus  were  prominent  symptoms. 
The  paroxysms  in  the  graver  form  were  separated  by  a  period  of  remission 
rather  than  by  a  distinct  intermission.  These  cases  were  rare,  but  often 
fatal,  the  patient  falling  into  a  condition  of  collapse,  which  often  lasted 
for  some  days  before  death  occurred.  This  form  corresponds  with  that 
which  has  been  described  by  recent  observers  as  "  bilious  typhoid.''^  It 
has  occurred  with  varying  frequency  in  many  of  the  epidemics  of  relaps- 
ing fever,  and  has  had  much  to  do  in  determining  the  high  death-rate  in 
some  of  them,  notably  in  the  Russian  epidemic  of  1864-65.  Bilious  ty- 
phoid, which  has  not  occurred  in  any  of  the  outbreaks  of  relapsing  fever  in 
America,  was  first  fully  described  by  Griesinger,^  who  observed  it  at 
Cairo  in  1851,  and  gave  it  this  name. 

ANALYSIS     OF     THE     PrIXCIPAL     SyMPTOMS. 
SYMPTOMS   REFEBABLE  TO   THE  NERVOUS  SYSTEM. 

Headache  is  an  early  and  persistent  symptom.  It  subsides  with  the  cri- 
sis only  to  recur  with  the  relapse,  in  which  it  is,  however,  often  somewhat 
less  intense.  It  is  commonly  frontal,  sometimes  general,  and  is  throbbing 
or  darting  in  character.  In  rare  instances  it  is  mild,  and  ceases  after  a 
day  or  two. 

Vertigo  is  very  common.  It  occurs  as  an  early  symptom,  and  patients 
often  declare  that  it  is  the  giddiness  rather  than  the  fever  that  forces 
them  to  take  to  bed  speedily -after  the  onset  of  their  illness.  This  symp- 
tom continues  throughout  the  primary  paroxysm,  and  returns  in  the  re- 
lapse; it  causes  the  patients  to  stagger  like  drunken  persons  when  they 
attempt  to  stand  or  walk. 

Delirium  is  rare.  When  it  exists  it  is  transitory,  but  is  apt  to  be  ac- 
tive and  noisy.  It  occurs  for  the  most  part  in  hysterical  or  intemperate 
persons.      In  most  cases  the  mind  is  unclouded  throughout  the  attack. 

Stupor  and  coma  occasionally  come  on  rather  suddenly  at  or  soon 

'  J.  Rose  Cormack,  M.D.  :  The  Natural  History,  Pathology,  and  Treatment  of  the 
Epidemic  Fever  at  present  prevailing  in  Edinburgh.     Edinb. ,  1843. 

-  See  Yirchow's  Ilandbucli  der  speciellen  Path,  und  Therap.  Band  II.,  Zweite 
Abtheil.  ;  also  Dr.  Van  Ilarlingen's  translation  in  Lebert's  article  in  Ziemssen'e  Cyclo- 
paKlia,  vol.  i. 


liELAPSING    FEVER.  325 

after  the  crisis,  in  consequence  of  suppression  of  urine.  They  may  be 
attended  with  general  convulsions.  The  patient  may  sink  into  persistent 
stupor,  with  dry,  brown  tongue,  muttering  delirium,  and  the  attendant 
symptoms  that  make  up  that  condition  known  as  the  "  typhoid  state,"  in 
consequence  of  the  intensity  of  the  fever.  This  is  rare,  but  v?hen  it  takes 
place  the  crisis  does  not  occur,  and  the  condition  is  one  of  the  greatest 
danger. 

Insomnia  is  often  marked,  and  occasions  great  distress;  it  is  in  large 
measure  due  to  the  pains.  In  the  cases  observed  by  Dr.  Parry  it  was  a 
much  more  prominent  symptom  in  the  early  than  in  the  later  months  of 
the  epidemic.  Sleeplessness  attended  in  many  of  his  cases  the  primary 
paroxysm,  the  remission,  the  relapse,  and  the  period  of  convalescence;  it 
did  not  yield  to  the  administration  of  hypnotics.  Toward  the  end  of  the 
outbreak  it  was  a  less  gi-ievous  symptom,  and  was  easily  controlled  by 
lemedies. 

Debility  is  an  early  symptom.  That  it  should  become  marked  toward 
the  end  of  the  sickness  is  apparent  from  a  consideration  of  the  symptoms 
that  attend  the  attack.  In  most  instances,  however,  the  patient  is  able 
to  get  out  of  and  into  bed  again,  and  to  help  himself. 

Pain. — Among  the  more  characteristic  and  distressing  symptoms  of 
relapsing  fever  are  the  severe  joains  in  the  muscles  and  joints  complained 
of  by  almost  all  the  patients.  Pain  in  the  back  is  severe  during  the  first 
few  days.  The  other  pains  are  also  present  from  the  beginning;  they 
continue  throughout  the  paroxysm  and  the  relapse.  In  many  cases  they 
are  also  present  during  the  intermission;  at  this  period  they  are  apt  to 
be  more  distinctly  articular,  but  are  unattended  by  swelling  or  by  any 
grave  difficulty  of  treatment.  The  muscle-pains  are  seated  in  the  neck, 
chest,  and  abdomen,  as  well  as  in  the  extremities;  they  are  usually  most 
severe  in  the  lower  limbs,  and  in  particular  in  the  calves  of  the  legs. 
They  arise  spontaneously,  but  are  also  excited  by  pressure  and  by  volun- 
tary movement,  and  compel  the  patient  to  preserve  as  nearly  as  possible 
a  motionless  attitude  in  bed.  They  are  described  as  resembling  the  neu- 
ralgic pains  that  follow  unaccustomed  or  over-prolonged  use  of  certain 
groups  of  muscles.  Subsiding  during  convalescence,  they  leave  behind 
them  marked  muscular  weakness. 

Muscular  palsies  will  be  considered  among  the  sequels.  Retention  of 
urine  and  involuntary  evacuations  are  very  rare.  When  they  occur,  it  is 
in  consequence  of  sudden  syncope  or  cerebral  complications  attendant 
upon  urasmia.  Involuntary  fecal  discharges  are  sometimes  due  to  ex- 
treme diarrhoea  in  grave  cases.  Tremors  are  not  observed  except  in  the 
subjects  of  previous  alcoholism. 


326  THE  CONTINUED  FEVERS. 


THB  PHENOMENA  OF  THE  FEVEB. 

The  temperature  rises  with  great  rapidity,  and  attains  a  height  infre- 
quent in  the  other  fevers.  Its  course  is  characteristic  of  the  disease. 
During  the  initial  rigor  it  is  often  as  high  as  39°  C.  (102.2°  F.),  and 
within  twenty-four  hours  it  attains  40°— 41°  C.  (104°— 105.8°  F.).  The 
maximum  of  temperature  may  be  attained  upon  the  first  day,  during  the 
mid-course  of  the  paroxysm  or  shortly  before  the  crisis;  the  last  is  the 
most  frequent,  and  at  this  period  the  temperature  occasionally  runs  up 
rapidly  in  the  course  of  a  few  hours.  The  curve  is  irregularly  remittent, 
the  morning  temperature  being  from  1°  to  1.5°  C.  (1.8° — 2.7°  F.)  lower 
than  that  of  the  midday  or  evening.  Occasionally  the  remissions  are 
much  more  marked,  but  the  variations  are  neither  constant  for  different 
days  nor  for  the  same  hour  of  successive  days;  in  some  cases  they  do  not 
amount  to  more  than  a  few  tenths  of  a  degree,  and  it  is  not  uncommon 
to  note  a  higher  temperature  about  noon,  or  early  in  the  afternoon,  than 
in  the  evening.  In  rare  cases  the  diurnal  curve  shows  no  remission  what- 
ever, the  evening  and  the  morning  temperature  being  alike.  The  remit- 
tent type  is  most  constantly  present,  and  is  most  distinctly  marked  in 
children. 

In  no  other  disease  is  so  decided  and  so  rapid  a  critical  defervescence 
met  with  as  in  relapsing  fever.  It  is  always  sudden,  very  frequently 
preceded  by  an  increase  in  the  severity  of  the  symptoms,  and  sometimes 
ushered  in  Avith  a  chill.  It  commonly  occurs  in  the  evening  or  toward 
morning,  and  is  complete  as  a  rule  in  the  course  of  a  few  hours.  The 
temperature  falls  from  3° — G°  C.  (5.4° — 10.8°  F.)  in  cases  that  may  be 
spoken  of  as  average  instances,  and  it  is  not  uncommon  to  observe  a  fall 
of  even  7°  C.  (12.G°  F.)  within  a  short  time.  Murchison  informs  us  that 
falls  of  13°  F.  in  six,  and  14.4°  F.  in  twelve  hours,  have  been  noted.  A 
comparison  of  the  temperatures  of  the  febrile  paroxysm  and  the  fall 
during  the  defervescence,  indicates  a  subnormal  temperature  as  almost 
constant  at  the  termination  of  the  crisis.  This  is  found  to  be  the  case. 
It  is  not  rare  to  find  the  temperature  at  this  period  as  low  as  36° — 35°  C. 
(9G.8° — 95°  F.),  or  even  much  lower.  According  to  the  author  last  re- 
ferred to,  94°  F.  and  even  92°  F.  have  been  recorded,  and,  in  one  instance 
where  collapse  supervened,  a  rectal  temperature  of  90.6°  F.  was  observed. 
After  two  or  three  days  it  rises  to  the  normal  in  the  morning,  and  becomes 
subfebrile  in  the  evening,  and  then,  becoming  that  of  health  for  a  time, 
it  again  rises  slightly  upon  the  approach  of  the  relapse. 

A  temperature  of  39°  C.  (102.2°  F.)  or  more,  attends  the  onset  of  the 
relapse,  in  which  the  same  rapid  rise  to  a  great  height,  and  an  even  more 
rapid  fall  to  below  the  normal  standard  than  in  the  primary  paroxysm,  are 
encountered.     The  maximum  tempei-ature  of  the  whole  attack  is  not  in' 


RELAPSING    FEVER. 


327 


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I 


3 28  THE    CONTINUKD    FEVEKS. 

frequently  met  with  in  the  ruhipbc.  The  crisis  is  acconi})anied  by  free 
perspiration.  If  other  relapses  follow,  the  temperature  curve  attending^ 
them  is  the  same,  but  the  fever  is  of  shorter  duration. 

The  maximum  temperature  of  relapsing  fever  varies  from  41°  to  42"  C. 
(105.8° — 107.G°  F.)  in  cases  that  cannot  be  looked  upon  as  exceptional.  A 
temperature  of  even  42.5°  C.  (108.5°  F.)  has  been  observed.  These  ex- 
cessively high  temperatures,  if  not  long  continued,  are  not  attended  with 
great  danger  to  the  patients,  nor  do  they  give  rise  to  cerebral  symptoms. 
In  this  respect  relapsing  fever  differs  from  other  diseases  characterized  by 
intense  pyrexia. 

The  foregoing  statements  are  based  upon  observations  of  temperatures 
taken  in  the  axilla. 

The  pulse  is  always  frequent.  It  is  commonly  above  112,  but  may 
vary  from  90  to  120,  or  even  beat  as  rapidly  as  160  or  170  per  minute.  It 
is  more  frequent  by  20  or  30  beats  in  childhood  than  in  adult  life.  This 
frequency  is  attained  very  early  in  the  course  of  the  disease.  It  is  not 
of  unfavorable  prognostic  omen.  The  number  of  beats  per  minute  in- 
creases toward  evening  and  with  a  rising  temperature.  A  gradual  or 
progressive  increase  does  not  occur  with  the  progress  of  the  attack,  al- 
though it  is  not  uncommon  to  find  a  sudden  increase  in  pulse-rapidity,  as 
well  as  a  decided  sudden  rise  in  temperature,  immediately  preceding  the 
crisis. 

With  the  defervescence  there  is  a  sudden  fall  in  the  pulse-rate  to  the 
normal,  and  often  below  it.  In  a  few  hours,  declining  a  little  before  the 
temperature  begins  to  fall,  it  may  change  from  140  to  48 — 54.  During  the 
intermission  it  is  often  abnormally  slow,  40 — GO;  but  if  the  patient  leave  his 
bed  it  becomes  more  rapid,  100  or  more  upon  his  assuming  the  upright 
posture,  and  continues  to  beat  rapidly.  There  is  no  constant  ratio  be- 
tween the  rate  of  the  pulse  and  the  temperature.  Murchison  states  that 
there  is  less  correspondence  between  them  in  the  relapse  than  in  the  pri- 
mary paroxysm,  a  pulse  not  exceeding  90  being  sometimes  met  with 
where  the  thermometer  marks  a  temperature  of  106°  F. 

The  pulse  during  the  febrile  paroxysms  is  often  at  first  full  and  tense, 
but  with  the  crisis  it  becomes  small  and  feeble,  and  is  often  jerking  and 
irregular;  after  the  crisis  it  is  compressible,  and  not  seldom  dicrotic. 
With  convalescence,  as  the  patient  gains  strength,  the  pulse  resumes  its 
normal  character. 

About  the  time  of  the  crisis,  and  in  particular  immediately  after  it, 
the  impulse  and  first  sound  of  the  heart  are  often  very  greatly  impaired, 
and  sudden  death  from  syncope  may  take  place.  Within  the  course  of  a 
few  days,  and  with  the  use  of  stimulants,  the  heart  regains  its  power. 

A  soft  systolic  murmur  is  heard  over  the  cardiac  region  during  both 
paroxysms  in  frequent  cases  and  sometimes  in  the  intermission.  Its  area 
of  greatest  intensity  is  at   the  base;  it  is  propagated   in   the   course   of 


RELAPSING    FEVER. 


329 


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330  THE    CONTINUED    1-EVEKS. 

the  great  vessels,  and   becomes  faint   or  is   lost  entirely  in  the   erect  po- 
sition. 

The  urine  presents  the  characteristics  of  febrile  urine  in  general.  Its 
amount  varies  with  the  quantity  of  fluids  ingested,  and  is  influenced  by 
the  abundant  sweating  that  occurs  at  the  crisis,  and,  in  many  cases,  during 
the  progress  of  the  febrile  paroxysms.  As  a  rule,  it  is  diminished  in 
quantity  during  the  febrile  stages,  and  of  darker  color  and  higher  specific 
gravity  than  normal,  and  becomes  normal  or  even  increased  in  quantity 
shortly  after  the  crisis.  It  is  frequently  cloudy,  and  deposits  a  sediment 
consisting  of  the  urates;  less  often  uric  acid  is  present,  and  crystals  of  the 
oxalate  of  lime.  It  is  commonly  acid  in  reaction,  but  occasionally  alka- 
line when  passed.  The  triple  phosphates  are  present  in  the  latter  case. 
In  some  cases  the  amount  is  greatly  reduced  immediately  after  the  crisis, 
the  patients  being  exceedingly  weak  and  sweating  profusely.  Two  cases 
under  Parry's  observation  did  not  void  more  than  an  ounce  in  twenty- 
four  hours  for  several  days,  yet  there  was  no  evidence  of  uraemia. 

Albumen  in  small  amounts  is  often  present  in  the  urine  during  the 
primary  paroxysm,  and  Murchison  reports  a  case  in  which  copious  h.nema- 
turia  occurred  in  both  paroxysms,  although  the  urine  during  the  interval 
contained  no  trace  of  albumen.  Recovery  took  place.  Tube-casts  are 
found  along  with  the  albumen.  In  the  first  paroxysm  they  are  usually 
hyaline,  in  the  relapse  they  contain  granular  matter  and  oil-particles.  If 
pre-existing  Bright's  disease  complicate  the  case,  the  character  of  the 
urine,  especially  as  regards  the  quantity  of  albumen  and  the  nature  and 
abundance  of  the  renal  casts,  will  be  modified.  The  opinion  of  Obermeier,* 
that  acute  desquamative  nephritis  is  one  of  the  ordinary  phenomena  of 
relapsing  fever,  calls  for  a  closer  examination  into  this  point  in  future 
epidemics.  It  is  not  confirmed  by  other  recent  observers.  In  cases  com- 
plicated with  disease  of  the  kidneys,  and  under  other  circumstances, 
marked  diminution  or  suppression  of  urine  has  been  followed  by  ursemic 
symptoms,  such  as  delirium,  stupor,  coma,  and  convulsions.  This  con- 
dition is  apt  to  supervene  at  or  about  the  time  of  the  crisis.  Such  pa- 
tients have  in  many  instances  recovered  after  a  copious  discbarge  from 
the  kidneys.  Murchison  states  that  he  "  has  never  known  typhoid  symp- 
toms in  relapsing  fever  Avithout  albuminuria  or  some  other  evidence  of 
retarded  elimination  by  the  kidneys. 

In  those  cases  marked  by  jaundice,  bile-pigments  are  found  in  the 
urine;  the  biliary  acids  have  also  been  detected. 

TTie  s/chi  in  relapsing  fever  shows  no  characteristic  eruption.  The 
abundant  perspiration  gives  rise  to  plentiful  crops  of  sudamina.  Herpes 
facialis  occurs,  but  not  frequently.  Minute  petechise  are  occasionally 
observed  in  delicate  persons,  and  are  apt  to  be  most  abundant  upon  the 

'  Quoted  by  Murchison. 


RELAPSING    FEVER.  331 

lower  extremities.  Extensive  desquamation  sometimes  occurs,  and  durimr 
the  pyrexia  the  nutrition  of  the  nails  is  impaired,  as  is  shown  by  the  de- 
velopment upon  them  of  white  transverse  lines. 

SYMPTOMS   DUE  TO   DISTUBBANf'E   OF   THE  DIGESTrSTE   ORGANS. 

Thirst  and  loss  of  appetite  are  due  to  the  fever;  upon  the  defervescence 
the  former,  which  is  often  excessive,  ceases,  and  desire  for  food  returns; 
with  the  relapse  the  thirst  and  anorexia  reappear.  In  some  instances  au 
inordinate  desire  for  food  during  the  febrile  paroxysms,  and  especially  iu 
the  relapse,  has  constituted  a  remarkable  feature  of  the  disease.  Patients 
with  a  temperature  of  40°  C.  (104°  F.)  or  higher,  have,  in  some  instances, 
begged  for  solid  food  and  eaten  it  eagerly  iu  considerable  quantities 
without  apparent  injury — a  statement  attested  by  numerous  competent 
observers. 

The  tongue  is  usually  indented  at  its  edges  by  the  teeth,  and  covered 
with  a  whitish  or  yellowish-white  fur  of  varying  thickness.  In  other  in- 
stances the  fur  is  of  a  brownish  color  from  the  beginning.  The  edges 
and  a  triangular  space  at  the  tip  are  sometimes  clear  and  of  a  brighter 
red  than  normal.  The  papillae  are  enlarged  in  some  instances,  so  that  the 
tongue  may  be  likened  to  that  of  scarlet  fever  ;  less  commonly  the  organ 
is  red  and  glazed,  especially  in  the  relapse.  As  a  rule,  it  is  moist  through- 
out the  sickness;  but  it  may  show  a  dry,  brownish  streak  down  the  middle 
about  the  third  or  fourth  day.  It  sometimes  becomes  deeply  fissured — a 
very  painful  symptom.  In  very  severe  and  in  fatal  cases  it  becomes  dry, 
brown,  and  crusted,  and  sordes  collect  upon  the  teeth  and  lips.  The  fore- 
going facts  being  considered,  it  may  be  stated  that  the  tongue  iu  re- 
lapsing fever  presents  no  constant  characteristic  appearance. 

JVhusea  and  vomiting  are  common  symptoms.  They  appear  early  and 
soon  subside.  In  some  cases,  however,  the  vomiting  persists  to  the  end 
of  the  paroxysm,  ceasing  with  the  crisis,  but  returns  with  the  relapse  iu 
some  few  instances. 

The  vomited  matters  consist  of  the  substances  taken  into  the  stomach, 
of  gastric  mucus,  and  of  bile.  They  are  of  a  greenish  or  yellowish  color, 
and  are  usually  scanty.  "  Black  vomit  "  was,  in  rare  cases,  observed  in 
some  of  the  earlier  epidemics.     Hsematemesis  has  also  been  noted. 

Pain  and  tenderness  in  the  epigastrium  are  present  in  a  large  propor- 
tion of  the  cases.  They  are  frequently  associated  with  vomiting,  but  are 
by  no  means  proportionate  to  its  urgency.  The  pain  is  usually  slight  ; 
it  may,  however,  be  so  severe  as  to  interfere  with  respiration  (Murchison). 
It  may  be  limited  to  the  epigastrium,  or  extend  across  the  epigastric  zone. 
In  the  latter  case  it  is  most  severe  in  the  left  hypochondrium,  and  is  patho- 
logically referable  to  the  acute  enlargement  of  the  spleen. 

Enlargement  of  the  liver  occurs  iu  most  of  the  cases.    It  appears  later 


3;}2  THE    CONTINUED    FEVERS. 

than  the  enlargement  of  the  spleen,  and  is  much  less  marked.     It  is  at 
tended  with  pain  upon  pressure  in  the  hepatic  region. 

Jaundice  appears  in  varj-ing  frequency  in  different  epidemics.  It  has 
seldom  been  observed  in  more  than  twenty  per  cent,  of  all  cases,  and  is,  as 
a  rule,  still  less  frequent.  It  rarely  appears  earlier  than  the  third  or  fourth 
day  of  the  primary  paroxysm,  and  in  some  instances  not  until  the  crisis. 
If  it  comes  on  in  the  first  paroxysm,  it  usually  fades  rapidly  during  the 
intermission.  With  the  relapse  it  may  again  deepen;  it  sometimes  does 
not  appear  before  this  stage  of  the  fever.  It  is  usually  slight  and  disappears 
in  the  course  of  a  few  days;  in  some  cases,  however,  it  is  intense  and  per- 
sistent. It  occurs  in  all  ages,  but  is  most  frequent  in  the  middle  periods 
of  life.  Its  presence  imparts  to  the  physiognomy  an  appearance  not  com- 
mon in  the  fevers  of  temperate  climates. 

Jaundice  is  not  in  itself  a  dangerous  symptom.  In  severe  cases  it  is 
sometimes  associated  with  albuminuria. 

Enlargement  of  the  spleen  is  a  constant  symptom.  So  rapid  is  the 
alteration  in  the  volume  of  this  viscus  that  the  enlargement  may  often  be 
detected  within  twenty-four  hours  of  the  beginning  of  the  attack,  and  it 
not  infrequently  amounts  to  two  or  three  times  its  normal  bulk.  It  pro- 
jects below  the  margin  of  the  ribs,  and  may,  even  at  its  maximum,  which 
is  attained  about  the  close  of  the  primary  paroxysm,  give  rise  to  visible 
bulging  of  the  surface  of  the  abdomen.  It  rapidly  decreases  during  the 
apyretic  period,  but  again  enlarges  in  the  relapse.  During  the  con- 
valescence it  rapidly  diminishes  in  size,  but  more  or  less  enlargement  may 
often  be  detected  for  a  long  time  after  the  attack. 

Tlie  stools  may  retain  their  normal  color  and  consistence,  but  not  in- 
frequently they  are  darker  than  in  health.  Intestinal  catarrh  sometimes 
gives  rise  to  more  or  less  persistent  diarrhoea. 

Hemorrhages  are  met  with.  Epistaxis  is  not  infrequent.  It  has  been 
observed  oftener  in  childhood  than  in  adult  life.  It  is  sometimes  so  severe 
-as  to  require  plugging  of  the  nares.  Hasmaturia  has  already  been  alluded 
to.  Intestinal  bleeding  may  also  occur,  but  is  not  a  common  accident  of 
this  disease.  The  catamenia  occurring  during  the  progress  of  relapsing 
fever  are  apt  to  be  profuse.  Severe  uterine  hemorrhage  may  occur  in 
■connection  with  abortion. 

Complications  and  Sequels. 

Mild  bronchitis  is  not  uncommon.  It  usually  requires  no  treat- 
ment, and  interferes  but  little  with  the  progress  of  the  case  or  with 
recovery. 

Pneumonia  occurs  as  a  complication  in  some  epidemics.  It  usually 
appears  in  the  course  of  the  primary  paroxysm  or  in  the  relapse.  In  the 
<5ases  observed  by  Lebert  in  the  epidemic  of  1868-69,  in  IBreslau,  it  showed 


I 


RELAPSING    FEVER.  333 

a  strong  tendency  to  become  double,  and  was  in  severe  cases  the  cause  of 
deatli.     In  rare  cases  pneumonia  terminates  in  gangrene. 

Pleurisy  occasionally  occurs.  On  the  left  side  it  may  arise  as  a  sec- 
ondary lesion  to  splenic  abscess. 

Chronic  indmonary  affections  appear  to  be  but  little  influenced  by 
the  disease. 

When  the  subjects  oi  fatty  degeneration  of  the  heart  are  attacked  by 
relapsing  fever,  there  is  danger  of  sudden  death  from  syncope.  This  un- 
toward accident  may  take  place  in  the  first  paroxysm,  in  the  intermission,, 
or  in  the  relapse.  It  has  been  perhaps  more  frequently  noted  at  or  about 
the  time  of  the  first  crisis.  Sudden  collapse  and  death  from  heart-failure 
may  also  occur  in  consequence  of  other  forms  of  organic  disease,  and 
cases  have  been  observed  in  which  sudden  death  has  occurred  shortly  after 
the  patient  has  appeared  to  be  doing  well  and  the  disease  seemingly  run- 
ning a  mild  course,  without  the  post-mortem  discovery  of  any  lesion  ade- 
quate to  account  for  it. 

Acute  laryngitis,  with  oedema,  has  in  more  than  one  instance  neces- 
sitated the  performance  of  tracheotoni}'^  in  the  course  of  relapsing  fever. 
Dr.  Begbie*  mentions  a  case  of  this  kind,  in  which  the  complication  was 
ascribed  to  peculiar  exposure  to  cold  during  the  fever. 

Gangrene  of  the  feet,  nose,  ears,  and  lips  have,  in  rare  instances,  oc- 
curred, in  consequence  of  arterial  thrombosis. 

Splenic  enlargement  may  persist  for  a  considerable  time  after  the  at- 
tack, and  is  in  such  cases  to  be  regarded  as  a  sequel.  It  is  of  two  kinds: 
first,  painless  and  associated  with  profound  anasmia;  and  second,  tender 
upon  pressure,  and  accompanied  by  fever  of  remittent  type. 

Abscesses  of  the  spleen  occur  in  rare  instances.  They  give  rise  to  pyse- 
mic  symptoms,  and  may  be  the  cause  of  acute  peritonitis  or  left  pleurisy, 
or  they  may  burst  into  the  descending  colon.  The  softened  spleen  may 
rupture  during  the  paroxysm,  and  cause  death  by  hemorrhage  into  the 
peritoneum.  In  view  of  the  possibility  of  this  accident,  palpation  of  the 
splenic  area  is  to  be  performed  with  great  circumspection. 

Anaemia  is  very  commonly  a  sequel  of  relapsing  fever.  It  is  usually 
marked,  sometimes  attended  with  puffy  eyelids  and  oedema  of  the  lower 
extremities.  It  gradually  amends,  but  in  some  cases  is  persistent. 
Antemic  murmurs  are  common. 

Subcutaneous  abscesses,  parotid  swelling,  and  buboes,  occur,  in  very 
rare  instances,  during  the  convalescence. 

JErysijjelas  also  occurs,  and  is  sometimes  fatal. 

Diarrhoea  is  not  an  uncommon  complication  and  sequel.  In  some 
epidemics  it  has  been  the  cause  of  a  considerable  proportion  of  the  deaths. 
It  is  occasionally  critical, 

'  Reynolds'  System,  vol.  i.,  article  Relapsing  Fever.     By  J.  Warburton  Begbie,  M.D. 


334  THE  CONTINUED  FEVERS. 

Dysentery  is  also  mentioned  as  a  sequel.  It  is,  in  rare  instances,  tlie 
cause  of  peritonitis. 

Pains  hi  the  muscles  and  Joints,  and  various  neuralgias,  are  very  con- 
stantly annoying  symptoms  during  the  early  days  of  the  convalescence. 
With  regaining  strength  and  improved  nutrition  they  pass  awa\\ 

Local  palsies  are  infrequent  after  relapsing  fever.  Paralysis  of  the 
deltoids,  and  the  flexors  of  one  or  both  forearms,  has  been  observed. 
Paresis  of  the  muscles  of  the  uj^per  and  lower  extremities  has  been  noted 
witli  greater  frequency.  The  loss  of  power  comes  on  suddenly  in  the  early 
days  of  convalescence,  and  is  accompanied  by  numbness.  It  is  transient, 
And  disappears  in  the  course  of  a  week  or  ten  days. 

Lebert  alludes  to  hceniorrhagic  2)achy)/ieninyitis  as  a  sequel,  and 
states  that  it  was  frequently  encountered  in  the  St.  Petersburg  epidemic. 

Inflammatory  affections  of  the  internal  structures  of  the  eye,  such  as 
iritis,  choroiditis,  and  retinitis,  have  occurred  with  considerable  frequency 
■during  the  late  convalescence  in  some  of  the  epidemics. 

These  affections  never  occur  as  sequels  of  typhus  or  enteric  fever. 
They  have  been  described  by  various  authors  under  the  name  of  "post- 
febrile ophthalmia,"  and,  in  particular,  the  accounts  given  by  Macken- 
zie '  and  Dubois  "^  are  of  interest  among  the  earlier  descriptions. 

Quite  recently,  Dr.  Julius  Trompetter  "'  reported  that,  in  three  hundred  and  twenty- 
five  cases  of  relapsing  fever  in  Breslau,  twenty-one  cases  of  choroiditis  were  observed  ; 
they  were  nearly  all  of  the  acute  form.  On  admission  to  hospital,  the  patients  mostly 
presented  the  characters  of  well-marked  choroiditis  in  the  fonn  of  cyclitis.  Very  fre- 
quently hypopyon  appeared,  without  inflammatory  phenomena  on  the  part  of  the  iris. 
Turbidity  of  the  vitreous  humor  was  ascertained  to  be  present  in  all  the  cases,  and 
the  visual  acuity  was  always  considerably  impaired  at  the  commencement  of  the  ill- 
ness. The  field  of  vision  showed  a  limitation  of  the  periphery  in  all  directions.  The 
course  of  the  choroiditis  was  in  general  favorable  ;  its  average  duration  was  from  a 
month  to  six  weeks.  In  two  cases  both  eyes  were  affected.  Dr.  Trompetter  believes 
that  the  affections  of  the  eye  in  relapsing  fever  are  due  to  embolism  arising  from  par- 
tial necrosis  and  abscess  of  the  .spleen. 

In  a  recent  epidemic  of  relapsing  fever,  at  Konigsberg,  Dr.  Luchhau  has  also  in- 
vestigated the  frequency  of  ear  and  eye  complications.  No  less  than  three  hundred 
cases  were  treated  in  the  town  hospital.  Of  this  number  only  one  hundred  and  eighty 
cases  were,  however,  specially  examined  as  to  the  existence  of  ear  complications,  and 
these  were  found  in  fifteen  only,  and  in  all  the  middle  ear  was  the  part  affected.  In 
most  cases  there  was  suppuration,  and  the  pus  was  evacuated  through  the  tympanic 
membrane.  In  most  cases  of  disease  of  the  middle  ear  in  acute  maladies  the  inflamma- 
tion appears  to  arise  by  extension  from  the  throat;  but  it  was  found  that,  in  re- 
lapsing fever,  pharyngeal  catarrh  is  absent,  as  a  rule,  in  the  cases  in  which  the  middle 

'W.Mackenzie,  M.D.  :  Account  of  the  Epidemic  Remittent  Fever  at  Glasgow  in 
1843,  and  of  the  Post-febrile  Ophthalmitis.    London  Medical  Gazette,  vol.  xxiii.,  18-48. 

-  Relapsing  Fever  and  Ophthalmitis  Post-febrilis  in  Xew  York  :  Trans.  American 
Med.  Assn.,  1848. 

^  Klinische  Monatsbliitter  f  iir  Augenheilk. ,  January,  1880. 


KELAPSING    FEVER.  335 

•ear  suffers,  and  there  was  no  evidence  of  disease  of  the  Eustachian  tubes.     The  progno- 
sis is  not  unfavorable  if  prompt  treatment  is  adopted. 

Only  six  cases  presented  e^'e  symptoms  out  of  the  hundred  and  ei^jhty  examined 
(three  and  a  half  per  cent.).  In  three  there  was  iritis,  which  was  unilateral  in  every 
ca.se.  All  these  cases  did  well.  In  one  case,  however,  some  weeks  later,  the  patient 
complained  of  failure  of  sight,  and  opacities  were  discovered  in  the  vitreous.  In  two 
other  cases  optic  neuritis  occurred.  In  one  the  affection  was  discovered  in  the  first 
relapse.  The  second  relajjse  was  severe,  and  some  time  afterward  there  was  atrophy  of 
the  optic  nerves,  and  vision  was  reduced  to  one-tenth.  In  the  other  case,  the  neuritis  also 
occurred  during  the  second  febrile  attack  ;  a  few  days  after  it  had  ceased,  the  swelling 
of  the  optic  papilla  was  discovered,  dirty  red  in  color,  with  arteries  narrowed  and  veins 
d.steiided  and  somewhat  tortuous.  Vision  was  reduced  to  one-third  in  one  eye,  and  one- 
tifth  in  the  other.  Another  patient  came  into  the  hospital  during  the  first  relapse  with 
iritis  and  hypopion.  The  ocular  trouble  healed  completely,  but  after  the  relapse  the 
patient  insisted  on  leaving  the  hospital  and  passed  through  the  second  relapse  at  home, 
under  very  unfavorable  conditions.  When  it  was  over  he  returned  to  the  ho.spital  with 
doable  irido-cyclitis.  Numerous  thick  tlakes  were  seen  in  the  vitreous,  the  fundus  was 
very  indistinct,  but  the  papillae  were  seen  to  be  red  and  swollen,  and  there  were  numerous 
retinal  hemorrhages.  The  account  of  these  cases  is  published  in  the  October  number 
of  Virchow's  Archie. ' 


Prognosis  and  Mortality. 

Ill  general  terms  the  prognosis  in  relapsing  fever  is  favorable,  the 
death-rate  being  low. 

Death  occurs,  not  directly  in  consequence  of  the  fever,  except  in  rare 
instances,  but  by  reason  of  some  complication,  as  feebleness  of  the  heart, 
urfemia,  peritonitis,  pneumonia,  or  abortion.  It  may  take  place  during 
the  paroxysm,  the  intermission,  the  relapse,  or  after  the  second  critical 
defervescence. 

Of  2,115  cases  admitted  to  the  London  Fever  Hospital  from  1847  to 
1870,  according  ■  to  Murchison,  39,  or  1.84  per  cent.,  or  about  1  in  54, 
proved  fatal.  Deducting  from  this  number  10  cases  fatal  within  forty- 
■eight  hours  after  admission,  the  death-rate  was  only  1.38  per  cent.,  or  less 
than  1  in  73.  An  analysis  of  the  statistics  of  the  Scotch  epidemics  made 
by  the  same  author,  give  for  one  series  of  G,300  cases  a  mortality  of  260, 
or  4.12  per  cent.,  or  1  in  24.23  ;  and  for  a  second  series  of  10,444  cases, 
462  deaths,  or  4.42  per  cent.,  or  1  in  22.6.  These  two  series  of  cases,  taken 
in  connection  with  the  statistics  of  the  London  Fever  Hospital  for  the 
period  mentioned,  give,  in  a  total  of  18,859  cases,  761  deaths,  a  mortality 
in  England  and  Scotland  of  4.03  percent.,  or  1  in  24.78.  Lebert  informs 
us  that  in  three  epidemics  in  Breslau  the  mortality  did  not  rise  above  two 
to  three  per  cent. 

In  the  Russian  epidemic  of  1864-65,  of  12,382  cases,  1,574  terminated 

'  Lancet,  Dec.  11,  1880. 


30 

40 

40 

50 

50 

GO 

GO 

70 

70 

80 

Age  doubtful 

1, 

336  THE    COJ!iTINUED    FEVERS. 

fatally,  being  12.7  percent.,  or  1  in  7.8G — the  highest  recorded  death-rate 
in  any  epidemic. 

The  death-rate  increases,  in  adult  life,  progressively  with  the  age  of 
the  patient.  During  childhood  and  adolescence,  relapsing  fever  is 
scarcely  ever  fatal.  Reverting  again  to  the  statistics  of  the  London 
Fever  Hospital,  we  find  that,  of  the  2,115  cases  admitted,  there  were: 

Under  20  years,  804  cases,  3  deaths,  or  0.37  per  cent. 

Between  20  and  30       "      5G2  "  4  "  0.71        " 

'      322  "  8  "  2.48 

'      232  "  G  "  2.58        " 

'      119  "  0  "  7.56 

'        6G  "  7  "  10.60        " 

'          6  "  2  "  33.33        " 

4  "  0 

The  death-rate  is,  according  to  almost  all  published  statistics,  a  little 
higher  in  the  male  than  in  the  female  sex.  This  is  due  to  incidental  cir- 
cumstances. As  in  other  epidemic  diseases,  the  mortality  is  greatest  at 
the  outbreak  and  during  the  height  of  epidemics. 

AxATOMiCAL  Lesions. 

No  constant  anatomical  lesion  is  found  after  death.  The  spirilli  are 
discoverable,  in  some  instances,  in  the  blood,  if  deatli  takes  place  during 
the  pyretic  stages  (Guttmann).  But  they  have  been  sought  for  in 
vain  in  the  spleen,  lungs,  and  other  organs,  although  the  possibility  of 
their  existence  can  by  no  means  be  denied  (Lebert). 

The  body  is  often  emaciated;  the  skin,  in  addition  to  the  cadaveric 
discolorations  common  after  the  infectious  diseases,  shows  petechife,  if 
they  were  present  during  life;  the  jaundice  persists,  and  even  deepens 
(Murchison).  The  color  and  texture  of  the  muscles  is  unchanged;  but, 
upon  microscopic  examination,  there  is  not  infrequently  found,  especially 
when  death  has  taken  place  after  a  protracted  illness,  granular  infiltration 
of  the  muscular  fibres,  amounting  sometimes  to  fatty  deg'eneration. 
Cadaveric  rigidity  appears  early,  and  continues  for  a  considerable  time. 

The  stomach  is  usually  normal,  but  small  extravasations  of  blood  are 
met  with  in  the  mucous  membrane  of  this  viscus,  and  in  other  mucous 
and  serous  membranes.  This  has  been  particularly  observed  in  those 
cases  in  which  urgent  vomiting  has  preceded  death,  or  in  those  charac- 
terized by  black  vomit. 

T7i,e  intestines  are  normal,  except  in  cases  in  which  diarrhoea  or  dys- 
entery has  occurred.  After  the  former,  injection  of  the  mucous  mem- 
brane, particularly  toward  the  lower  end  of  the  ileum,  is  seen;  after  dys' 
entery,  the  lesions  peculiar  to  that  affection  are  met  with. 


EELAPSING    FEVEE.  337 

The  solitary  follicles  are  sometimes  slightly  enlarged.  They  are 
never  ulcerated,  nor  are  the  agminate  glands  of  the  small  intestine. 
Slight  swelling  of  the  mesenteric  glands  is  sometimes  found. 

The  liver  is  slightly  or  moderately  enlarged,  and  deeply  congested, 
especially  when  death  occurs  during  the  pyrexia.  In  rare  instances,  it 
is  the  seat  of  small  deposits  of  a  dull  yellow  color,  softened  in  the  centre. 
The  gall-bladder  is  generally  filled  with  a  clear,  viscid,  yellow,  or  brown- 
ish bile. 

The  spleen  is  enlarged,  sometimes  to  two-  or  three-fold  its  normal  size. 
This  change,  except  in  cases  that  have  resulted  fatally  at  a  late  period, 
after  the  second  defervescence,  is  met  with  in  all  cases.  Its  capsule  is 
smooth,  very  tense,  and  clouded.  Upon  section  the  parenchyma  is  soft, 
in  many  cases  almost  diffluent.  It  may  present  a  homogeneous  appear- 
ance, or  the  Malpighian  corpuscles  may  be  seen  with  unusual  distinctness. 
Minute  roundish  or  irregular  deposits  of  a  dull  yellow  color,  similar  to 
those  found  in  the  liver,  are  frequently  met  with.  They  contain  granular 
detritus,  with  cell-elements  and  free  nuclei.  These  are  also  found  in  the 
lymph-follicles,  and  may  be  observed  in  different  sections,  in  all  stages, 
from  simple  follicular  enlargement  to  the  aggregations  of  detritus  (Lebert). 
Wedge-shaped  infarctions  are  occasionally  met  with,  either  firm  or  break- 
ing down,  but  without  demonstrable  embolic  origin.  If  the  spleen  be 
greatly  softened,  no  decided  structure  can  be  recognized.  If  death  take 
place  some  time  after  the  termination  of  the  relapse,  in  consequence  of 
any  complication,  the  spleen  is  found  to  be  reduced  in  size,  and  its  cap- 
sule shrivelled.  In  rare  instances  abscesses,  due  to  the  breaking  down  of 
the  infarcts  mentioned  above,  are  found  underlying  the  capsule  and  still 
more  rarely  the  spleen  is  found  to  be  ruptured. 

The  heart  presents  no  change  consequent  upon  the  processes  of  relaps- 
ing fever,  except,  in  some  instances,  after  protracted  illness,  slight  gran- 
ular infiltration  of  the  muscular  fibres.  Fibrinous  coagula  are  found  in 
the  heart  and  great  vessels,  together  with  fluid  blood. 

The  lungs  show  only  those  changes  which  attend  the  various  pulmo- 
nary complications  of  relapsing  fever.  These  are  chiefly  bronchitis  and 
pneumonia.  The  latter  is  often  double,  and  may  in  rare  cases  result  in 
gangrene.  The  signs  of  recent  pleural  inflammation  are  rarely  encoun- 
tered. Hypostatic  congestion  is  rare  as  compared  with  typhus  or  enteric 
fever. 

Diagnosis. 

If  regard  be  had  to  the  temperature,  but  little  difficulty  can  attend 
the  diagnosis  of  relapsing  fever,  even  in  the  beginning  of  epidemics. 
The  abrupt  and  unusual  rise  in  temperature,  the  slight  and  inconstant 
morning  remissions  and  frequent  midday  rather  than  evening  exacerba- 
tions, the  critical  defervescence  at  the   expiration  of  five  or  seven  days, 


338 


THE   CONTINUED   FEVEKS. 


and  the  rapid  decline  of  the  temperature  to  a  point  below  the  normal,  con- 
stitute a  group  of  phenomena  characteristic  of  this,  and  met  with  in  no 
other  disease.  The  acute,  progressive,  and  extreme  enlargement  of  the 
spleen,  the  coincident,  but  less  marked  increase  in  the  size  of  the  liver, 
the  tenderness  in  the  region  of  both  these  organs  and  in  the  epigastrium, 
and  the  muscular  pains,  are  also  diagnostic.  Equally  characteristic  is 
the  abrupt  relapse,  after  an  apyretic  period  of  several  days,  with  its  repe- 
tition of  the  symptoms  of  the  primary  paroxysm  and  the  extraordinary 
rise,  high  range  and  sudden  fall  of  the  temperature  to  a  point  below  the 
normal. 

Clinically,  relapsing  fever  and  typhus  are  widely  unlike.  "Whether 
they  are  equally  unlike  etiologically,  speaking  in  general  terms,  remains 
for  future  investigations  to  decide.  The  striking  fact  that  the  former, 
in  all  its  great  epidemics,  has  prevailed  in  connection  with  typhus,  and 
commonly  in  a  definite  relation  with  it  as  regards  the  progress  of  the 
epidemic,  being  proportionately  most  common  at  the  beginning  of  the 
outbreak,  less  so  as  the  epidemic  advances,  and  giving  place  wholly  to 
typhus  at  its  close — this  fact,  coupled  with  the  well-established  observa- 
tion that  relapsing  fever  patients  are  prone  to  typhus  after  convalescence, 
while  typhus  fever  patients  are  little  liable  to  suffer  from  relapsing  fever 
within  a  short  time,  makes  it  appear  most  possible  that  in  a  broad  sense 
these  two  fevers  are  due  to  closely  associated  causes. 

Prevailing,  as  they  so  constantly  did  in  the  early  epidemics,  together 
as  a  pestilence — known  by  the  simple  designation  of  "  fever,"  or  "  the 
fever,"  it  was  natural  to  regard  relapsing  as  a  mild  form  of  typhus  fever. 
The  error,  once  established,  was  overthrown  with  difficulty — a  difficulty  to 
which  the  nosological  method  of  the  continental  Avriters  has  contributed 
not  a  little.  By  this  method  the  typhus,  enteric,  and  relapsing  fevers, 
and  sometimes  others — for  the  designation  is  an  elastic  one — are  classed 
together  as  the  common  group  of  so-called  "  typhus  "  diseases,  the  first 
being  regarded  as  "  exanthematous  typhus,"  the  second  as  "  abdominal 
typhus,"  and  the  last  as  "  recurrent  typhus."  The  following  tabular  ar- 
rangement of  the  principal  phenomena  of  the  three  fevers  just  named,  will 
serve  to  show  how  unlike  they  are  in  their  clinical  aspects,  and,  at  the 
same  time,  to  present  in  the  most  concise  manner  their  more  important 
points  of  differential  diagnosis: 


TYPHDS. 

Essentially  an  epidemic 
disease,  although  endemic 
in  certain  localities. 

Highly  contagious. 
Attack      sudden,      often 
without  prodromes. 
Course  continuous. 


An  endemic  disease,  often 
sporadic,  but  occasionally 
appearing  in  circumscribed 
epidemics. 

Not  directly  contagious. 

Attack  generally  insidi- 
ous. 

Continuous. 


EEIiAPSING. 


An  epidemic  disease,  often 
the  congener  of  typhus. 


Contagious. 
Attack  sudden. 

Broken  by   a   period    of 
complete  apyrexia. 


EELAPSING   FEVEH. 


339 


TYPHUS. 

Duration  about  fourteen 
days ;  rarely  exceeds  twenty 
days. 

Defervescence  critical,  or 
by  very  rapid  lysis. 

True  relapse  so  rare  as  to 
be  almost  unknown. 

Face  deeply  flushed, 
dusky. 


Conjunctivas  deeply  in- 
jected ;  pupils  contracted. 

Delirium  and  stupor  ear- 
ly and  prominent. 

Abdominal  symptoms  ab- 
sent ;  constipation  the  rule  ; 
meteorismrave. 

Intestinal  hemorrhage  ex- 
tremely rare.  Acute  dysen- 
tery may  occur  dviring  con- 
valescence. 

Epistaxis  does  not  occur. 


Skin  pungently  hot, 
sometimes  emitting  a  pecu- 
liar odor. 

Eruption  deep  in  color, 
copious,  general  in  its  dis- 
tribution. 

Emaciation  slight. 


Pneumonia  and  bronchitis 
of  finer  tubes. 

Death  not  infrequent  at 
end  of  first  week,  and  often 
before  the  conclusion  of  the 
second. 

No  characteristic  lesions 
found  in  the  body  after 
death. 


From  three  to  four  weeks. 


Terminates  by  prolonged 
lysis. 

Relapses  occasionally  oc- 
cur ;  they  are  irregular,  in- 
constant, and  accidental. 

Face  pale ;  if  there  is 
flushing,  it  is  confined  to  the 
region  of  the  cheek-bones, 
and  is  circumscribed. 

Eyes  clear  ;  pupils  often 
dilated. 

Less  constant,  more  grad- 
ual in  development,  and  of 
longer  duration. 

Abdominal  symptoms 
prominent.  Diarrhoea  and 
meteorism  the  rule. 

Intestinal  hemorrhage  not 
unusual. 


Epistaxis  common. 

Skin  hot ;  sometimes 
bathed  in  acid  perspiration. 

Eruption  light  red,  sparse, 
discrete,  commonly  confined 
to  particular  regions  of  the 
trunk. 

Emaciation  great. 


Bronchitis  and  pleurisy. 


Death  usually  takes  place 
in  or  after  the  third  week. 


Constant  lesions  of  the 
ileum  and  the  mesenteric 
glands. 


RELAPSING. 

Duration  of  primary  par- 
oxysm from  five  to  seven 
days  ;  of  the  relapse,  about 
three. 

Ends  abruptly  by  crisis. 

Relapse  constant  and  an 
integral  factor  of  the  at- 
tack. 

Face  often  flushed;  the 
color  lacks  the  duskiness  of 
typhus,  and  is  not  circum- 
scribed, as  in  enteric  fever. 

Conjunctivaj  slightly  in- 
jected ;  pupils  natural. 

Mind  commonly  clear 
throughout. 

Pain  and  tenderness  in 
the  epigastric  zone.  Con- 
stipation the  rule ;  occasion- 
ally diarrhcea  sets  in  at  the 
crisis. 


Epistaxis  occasionally  oc- 
curs, especially  at  the  time 
of  the  crisis. 

Skin  hot ;  profuse  sweat- 
ing at  crisis. 

No  definite  eruption. 


Emaciation  not  marked, 
save  when  the  patient  has 
suffered  from  insufl[icient 
food  prior  to  his  illness. 

Bronchitis  common,  but 
rarely  severe.  Pneumonia 
occurs. 

A  fatal  issue  rare,  except 
in  consequence  of  complica- 
tions. 

Post-mortem  appearances 
not  characteristic. 


JRemittent  fever  is  to  be  diagnosticated  from  relapsing  fever  by  the 
marked  differences  in  the  range  of  temperature,  the  duration  of  the  at- 
tack, the  character  of  the  crisis,  the  length  of  the  intermission,  the  relapse, 
and  the  great  contagiousness  of  the  latter.  Moreover,  the  circiamstances 
under  which  the  diseases  appear  and  prevail  in  the  community  are  of  diag- 
nostic value. 


340  THE    CONTINUED    FEVERS. 


Treatment. 

Prophylactic  treatment  must  be  based  upon  our  knowledge  of  the  pre- 
disposing as  well  as  of  the  exciting  causes  of  the  disease.  Upon  the  ap- 
pearance of  relapsing  fever,  renewed  efforts  must  be  made  to  relieve  the 
sufferings  of  the  poor,  and  chiefly  to  provide  them  with  a  sufficient  quan- 
tity of  wholesome  food.  As  far  as  is  possible,  overcrowding  must  be  di- 
minished in  the  districts  most  liable  to  become  pestilential  centres  of  the 
disease.  The  drainage  is  to  be  looked  to,  and,  if  defective,  temporary 
measures  to  drain  away  stagnant  water  must  be  immediately  resorted  to. 
All  accumulations  of  filth  and  garbage  must  be  at  once  removed.  The 
system  of  visitation  among  the  healthy,  by  laymen  competent  to  instruct 
them  as  to  the  measures  proper  to  be  taken  with  the  view  of  avoiding  the 
disease,  that  w^as  instituted  in  Paris  during  the  cholera  epidemic  of  1849, 
is  suggested  by  Lebert. 

In  view  of  the  possibility  of  the  introduction  of  the  protomycetes  by 
drinking-water,  it  should  be  subjected  to  boiling.  Abundant  ventilation  is 
of  the  first  importance.  Contagious  as  relapsing  fever  is,  it  does  not 
spread,  even  when  cases  occur,  in  the  large  and  well-ventilated  houses  of 
the  opulent,  nor  to  any  great  extent  in  the  roomy  and  properly  aired 
wards  of  well-managed  hospitals,  except  to  those  whose  vocations  bring 
them  into  close  contact  with  the  sick.  As  has  already  been  stated,  phy- 
sicians visiting  from  house  to  house  among  the  poor,  remaining  only  a 
short  time  in  the  presence  of  the  patients,  and  passing  quickly  again  into 
the  open  air,  are  less  liable  to  contract  the  fever  than  the  resident  physi- 
cians of  hospitals,  who  pass  from  bedside  to  bedside,  without  the  opportu- 
nity, for  several  hours  at  a  time,  of  breathing  an  uncontaminated  atmos- 
phere. 

Cleanliness  of  the  abode  and  of  the  person  is  scarcely  second  in  import- 
ance to  abundant  ventilation.  The  contagium  is  readily  transmitted  by 
means  of  the  clothing  and  bedding  of  the  sick.  Soiled  clothes  should  be 
thrown  into  boiling  water  as  soon  as  taken  off,  and  carbolic  acid,  or  car- 
bolic acid  soap,  used  in  the  water  with  which  they  are  washed. 

If  patients  be  removed  to  a  hospital,  or  after  convalescence  has  set  in, 
the  apartment  should  be  fumigated  by  burning  sulphur,  thoroughly  aired, 
cleansed,  and  whitewashed.  It  is  obviously  impossible  to  treat  all  the 
rooms  in  the  densely  crowded  districts  of  cities  in  this  manner,  but,  in 
proportion  as  these  measures  are  promptly  and  generally  carried  into  ef- 
fect, will  the  spread  of  the  disease  be  retarded.  The  bedding  should  also 
be  subjected  to  the  sun  and  air,  and,  if  possible,  fumigated;  the  cheaper 
materials  used  in  filling  mattresses,  as  straw,  moss,  fine  shavings,  and 
husks,  should  be  burned. 

As  the  result  of  the  experience  of  all  observers  upon  an  extended 


RELAPSING    FEVER.  341 

scale,  it  may  be  stated  that  up  to  the  present  time  no  drug  or  method  of 
treatment  has  been  found  to  exercise  any  decided  influence  upon  the 
course  of  the  disease. 

It  is  scarcely  necessary  to  allude  to  hloodletting.  From  the  day  that 
relapsing  fever  was  distinguished  from  typhus,  it  was  clear  that  the  criti- 
cal defervescence  on  the  fifth  or  seventh  day  of  the  short  fever,  ascribed 
to  depletion,  was,  in  fact,  not  the  result  of  treatment  at  all,  but  an  event 
of  the  natural  course  of  the  disease. 

Repeated  cold  baths  and  large  doses  of  quinia  reduce  the  temperature, 
but  neither  aifect  the  duration  of  the  paroxysm  nor  prevent  the  relapse. 
Quinia  has  been  tried  in  vain,  in  moderate  and  large  doses,  both  during 
the  pyretic  period  and  in  the  intermission,     ArseniG\?>  likewise  ineffectual. 

The  observations  of  Dr.  Riess,'  of  Berlin,  are  of  great  interest.  Her 
found  sodium  salicylate  very  effective  in  reducing  the  temperature,  and, 
given  in  large  doses  during  the  intermission,  in  lessening  the  severity  of, 
and  apparently  even  sometimes  preventing,  the  relapse.  These  observa- 
tions are  to  be  tested  by  a  more  extended  investigation  of  the  value  of 
this  drug  in  future  epidemics. 

It  has  been  suggested  that  the  enormous  development  of  the  proto- 
mycetes  in  the  blood  during  the  paroxysm,  and  their  disappearance  during 
the  intermission,  are  strong  arguments  in  favor  of  the  administration 
of  parasiticides;  that,  with  this  view,  a  more  systematic  administration 
of  the  sulphites,  and  the  disengagement  of  sulphurous  acid  gas  in  the 
air  of  the  sick-apartment,  should  be  attempted.  Remedies  of  this  kind 
had  been  tried  without  success  before  Obermeier's  discovery.  Parry,  in 
1870,  administered,  without  in  the  least  abating  the  violence  of  the  course 
of  the  disease,  the  sulphites,  the  hyposulphites,  and  the  preparations  of 
chlorine.  The  destruction  in  the  blood  of  enormous  numbers  of  disease- 
producing  parasites — so  low  in  the  scale  of  existence  as  to  lie  upon  the 
most  distant  borders  of  independent  life — so  minute  that  they  dwell  in  the 
ultima  Thule  of  microscopic  vision — by  means  of  parasiticides  administered 
in  any  amount  short  of  compromising  the  integrity  of  the  blood  itself,  is 
highly  problematical.  Meanwhile,  relapsing  fever  must  be  treated  on  the 
expectant  plan. 

Rest  in  bed,  quietude,  abundance  of  fresh  air,  cleanliness,  a  carefully 
regulated  diet  consisting  of  milk,  broths,  meat-jellies,  light  farinaceous 
foods,  or,  if  the  patient  craves  them  and  can  digest  them,  even  the  stronger 
soups,  meat  and  vegetables,  but  always  plenty  of  cooling  drink,  will  in 
many  cases  suffice.     The  tendency  of  the  disease  is  to  recovery. 

The  patient  must  not  be  allowed  to  suffer  from  thirst.  Let  him  drink 
freely.  The  best  beverages  are  pure  water,  carbonated  water,  seltzer 
water,  or  milk  diluted  with  any  of  these.     If  he  prefer  it,  let  him  drink 

'Berlin,  klinische  Wochenschrift,  iii.,  1S79. 


342  THE  CONTINUED  FEVERS. 

water  acidulated  with  the  juice  of  lemons  or  limes,  or  let  him  take  ten 
or  fifteen  drops  of  dilute  phosphoric  or  muriatic  acid  every  three  hours, 
in  a  wineglassful  of  water  slightly  sweetened,  rinsing  his  mouth  and  teeth 
afterward. 

Cold  aj)pllcations  to  the  head,  by  means  of  ice  and  bran  in  bladders  or 
caps  of  india-rubber,  are  useful  in  mitigating  the  headache.  They  should 
be  applied  only  during  the  paroxysms  of  pain.  The  frequent  resort  to 
friction,  with  anodyne  linhnents  will  give  relief  to  the  muscle-pains.  For 
this  purpose — 

Yf..    Chloral  hydrate 16 — 32.00  gm.  \  ss. — j. 

Lin.  saponis  camph 200.00  c.c.  fl.  %  vj. 

M. 

or  a  lotion  consisting  of  equal  parts  of  chloroform  and  olive  oil,  may  be 
employed. 

If  the  pains  be  very  severe,  the  hyiyodermic  xise  of  vxorphia,  alone  or 
with  atropia,  will  be  required  to  relieve  them. 

Opium  and  its  derivatives,  by  the  stomach,  appear  to  have  in  very  many 
cases  but  little  effect,  either  in  relieving  pain  or  producing  sleep,  in  relaps- 
ing fever.  Parry  and  other  observers  state  that  a  remarkable  tolerance 
for  this  druff  was  established  during  the  attack. 

J^otassium  bromide  is  useless. 

Sleeplessness  will  yield  to  the  administration  of  chloral  hydrate  in 
moderate  doses.  This  drug  is  to  be  given  with  caution  where  the  action 
of  the  heart  is  enfeebled. 

An  eynetic,  followed  by  mild  purgatives,  is  of  use  in  relieving  the 
vomiting  and  pains  in  the  epigastric  zone.  At  the  same  time  sinapisms, 
hot  fomentations,  or  small  blisters,  should  be  applied.  Carbolic  acid  may 
also  be  given  for  the  nausea  and  vomiting.  If  the  pain  in  the  region  of 
the  spleen  is  very  great,  poultices  should  be  applied,  or  frequently  re- 
newed cold-water  applications  may  afford  relief. 

Alcoholic  stimulants  are  to  be  given,  not  as  a  part  of  a  general  routine 
treatment,  but  as  called  for  by  the  weakness  of  the  patient  and  the  char- 
acter of  the  pulse,  the  impulse  of  and  the  first  sound  of  the  heart.  At 
the  time  of  the  crisis  they  are  of  great  benefit,  and  must  be  given  during 
the  first  days  of  the  remission,  and  again  in  the  early  convalescence. 

If  collapse  threaten,  it  must  be  treated  by  prompt  stimulation  by  alco- 
hol, spirits  of  chloroform,  ammonium  carbonate,  artificial  heat,  and  so  on. 

Diarrhoea  calls  for  the  employment  of  astringents  and  opium. 

Bronchitis,  occurring  as  a  complication  of  relapsing  fever,  is  usually  of  a 
mild  form,  and  does  not  require  especial  therapeutic  intervention. 

Pneumonia  is  to  be  treated  upon  general  principles.  It  may  be  said 
that,  almost  without  exception,  intercurrent  pneumonias  call  for  increased 
stimulation. 


EELAPSING   FEVER.  343 

Parry,  after  trying  various  drugs,  found  that  quinia  in  combination 
with  camphor  was  most  useful,  during  the  intermission  and  in  the  early 
convalescence,  in  relieving  the  patient's  sense  of  prostration  and  inducing 
sleep. 

The  anaemia  of  convalescence  from  relapsing  fever  urgently  demands 
an  abundance  of  wholesome,  nutritious  food,  the  vegetable  tonics,  such 
as  the  best  preparations  of  cinchona  and  nux  vomica,  the  best-borne 
preparations  of  iron,  and,  if  the  pallor  be  protracted  and  the  patient  take 
it  well,  cod-liver  oil. 

Chronic  enlargement  of  the  spleen  should  be  treated  by  quinia  and 
iron,  and  externally  by  inunctions  of  the  red  iodide  of  mercury  oint- 
ment. 


VII. 

DENGUE. 

Definition. — An  acute,  febrile  affection,  of  short  duration,  due  to  an  un- 
known external  specific  cause,  and  prevailing  in  extensive  epidemics, 
which  are  chiefly  confined  to  warm  climates;  it  consists  of  two  dis- 
tinct, brief,  febrile  paroxysms,  each  attended  by  a  different  group  of 
symptoms,  and  separated  by  an  intermission  lasting  from  a  few  hours 
to  several  days.  The  first  is  characterized  by  continuous  high  fever, 
distressing  pains  in  the  joints  and  muscles,  interfering  with  motion, 
and  occasionally  by  a  cutaneous  efflorescence;  it  usually  terminates 
suddenly  with  some  critical  discharge;  the  second  paroxysm  is  marked 
by  a  milder  fever  of  remittent  type,  an  eruption  of  different  charac- 
ter, which  is  attended  with  intense  itching  and  followed  by  desqua- 
mation, by  some  recurrence  of  the  joint-pains,  and  by  debility;  it 
gradually  subsides.  The  disease  is  extremely  painful,  but  very 
rarely  fatal;  its  morbid  anatomy  is  therefore  unknown. 

Synonyms. — Febris  exanthematica  articularis;  Exanthesis  arthrosia; 
Exanthesis  rosalia  arthrodynia;  Scarlatina  rheumatica;  Scarlatina 
mitis;  Eruptive  articular  fever;  Eruptive  rheumatic  fever;  Rheu- 
matic fever  with  gastric  irritation  and  eruption;  Eruptive  epidemic 
fever  of  India;  Epidemic  inflammatory  fever  of  Calcutta;  Epidemic 
anomalous  disease;  Peculiar  epidemic  fever. 

Dandy  fever;  Polka  fever;  La  Piadosa;  La  Pantomina;  Colorado; 
Bouquet;  Bucket;  Giraffe;  Stiff-necked  fever;  Broken-wing  fever; 
Break-bone  fever;  Toohutia;  Three-day  fever;  Knockel  Koorts; 
Aburuka-Bah  (Father  of  the  Knee) ;  Date  fever. 

Dengue,  pronounced  dangay. 

"  This  disease,  wheii  it  first  appeared  in  the  British  West  India  Islands,  was  called 
the  dandy  fever,  from  the  stiffness  and  constraint  which  it  gave  to  the  limbs  and  body. 
The  Spaniards  of  the  neighboring  islands  mistook  the  term  for  their  word  dengue,  de- 
noting prudery,  which  might  also  well  express  stiffness,  and  hence  the  term  dengue 
Decame  at  last  the  name  of  the  disease." 

This  term,  begotten  of  a  misapprehension  of  a  word  applied  to  it  in 
jest,  has  become  the  generally  accepted  designation  of  the  disease. 


DENGUE.  345 

To  a  similar  origin  are  due  many  of  the  popular  names  by  which  it  is 
known  in  the  countries  where  it  has  prevailed.  The  people  are  often  dis- 
posed to  make  a  jest  of  epidemics  not  attended  by  danger  to  life,  the  more 
perhaps  when  the  sufferers  present  an  absurd  appearance.  The  Brazilians 
called  this  disease  \X\Q])olka  fever ;  the  Spanish, /apaw^omma/ the  French, 
bouquet  and  giraffe,  the  latter  because  of  the  stiff  manner  in  which  those 
affected  often  carry  the  head.  Stiff-necked  fever  and  broken-wing  fever  are 
likewise  terms  suggested  by  the  posture  of  the  convalescent;  while  break- 
bone  fever,  and  the  Batavian  designation,  Knockel  Koorts  (bone  fever), 
refer  to  the  torturing  joint-pains  that  attend  it.  In  Spanish-American 
countries  it  has  been  known  as  Colorado,  on  account  of  the  red  color  of 
the  eruptions.  It  is  probable  that  this  is  also  the  derivation  of  the 
French  term  bouquet.  Toorhutia  and  three-day  fever  are  East  Indian 
names  for  it;  and  aburuka-baJi  and  date  fever — the  latter  because  it  has 
been  observed  to  prevail  during  the  date-harvest,  are  Arabian  folk-terms. 

Medical  observers  have  designated  it  by  various  terms  of  classical 
derivation,  according  to  the  views  which  they  have  entertained  concern- 
ing its  nature.  Of  such  terms,  those  based  upon  its  fancied  relationship 
to  other  well-known  affections,  as  scarlet  fever  and  rheumatism,  are  inap- 
plicable now  that  it  is  known  to  be  a  distinct  affection;  others  fall  to  the 
ground,  because  they  are  based  upon  the  assumption  that  the  disease  is 
peculiar  to  a  country  or  locality,  now  that  it  has  become  known  as  pan- 
demic in  tropical  and  subtropical  climates;  while  others  still  fail  of  ac- 
ceptation because  they  are  not  suflBciently  distinctive. 


Historical  Sketch. 

Dengue  first  excited  general  attention  by  its  epidemic  prevalence  in 
the  West  India  Islands  in  1827.  Previous  to  that  date,  however,  it  had 
occurred  in  less  extended  outbreaks  in  tropical  countries  and  elsewhere. 
The  earliest  account  of  the  disease,  according  to  De  Wilde,'  dates  from 
the  year  1779.  David  Brylon,  the  chief  physician  of  Java  at  that  time, 
briefly  describes,  under  the  name  of  Knockel  Koorts,  an  epidemic  disease 
which  prevailed  among  the  natives  and  colonists.  Rush '  published  an 
account  of  an  epidemic  which  occurred  in  Philadelphia  in  the  following 
year,  1780.  The  disease  was  then,  as  now,  described  in  North  America 
as  break-bone  fever.  At  the  same  time  it  was  observed  by  the  missionary 
Wise,  according  to  an  anonymous  French  writer,'  on  the  coasts  of  Coro- 
mandel,  Africa,  Arabia,  Persia,  and  Thibet.     It  is  said  also  to   have  oc- 

'  J.  J.  de  Wilde  :  Dengue  in  Fort  William  I.,  in  Java.  Niedl.  Tijdschr.,  1873,  quo- 
ted by  Zuelzer. 

-  Medical  Enquirer  and  Observer,  1789. 
2  Zuelzer  :  Ziemssen's  Cyclopedia,  vol.  ii. 


346  THE  CONTINUED  FEVERS. 

curreJ  at  Lima,  in  January,  1818,  and  in  the  United  States,  at  Savannah, 
in  182G. 

Previous  to  the  general  epidemic  which  made  its  appearance  first  in 
September,  1827,  at  St.  Thomas,  there  exists  not  the  slightest  trace  in 
medical  literature  of  this  disease  in  the  West  Indies/ 

From  the  Island  of  St.  Thomas  it  spread  in  October  to  St.  Croix.  In 
these  islands  almost  every  inhabitant  in  a  population  of  13,000  suffered. 
It  passed  thence  toward  the  northwest,  over  the  great  Antilles  to  the 
main-land  of  North  America,  and  southward  over  the  Caribbean  Islands 
to  Columbia, 

Following  its  course  toward  our  own  country,  we  find  that  in  the  spring 
of  1828  it  had  reached  Pensacola,  and  that  it  spread  thence  in  June  to 
Charleston  in  one  direction,  and  in  the  other,  to  Mobile  and  New  Or- 
leans, where  it  prevailed  early  in  the  summer.  It  made  its  appearance  in 
Savannah  in  September.  In  the  same  year  sporadic  cases  were  observed 
iu  Boston,  New  York,  and  Philadelphia,  and,  according  to  some  accounts, 
in  some  of  the  cities  of  the  West,  although  the  evidence  in  regard  to  the 
last  statement  is  not  conclusive. 

In  the  beginning  of  the  year  1828,  the  disease  prevailed  in  Columbia, 
and  nearly  at  the  same  time  in  Porto  Rico,  Hayti,  and  Jamaica.  It  broke 
out  in  Cuba  in  March.  In  these  islands  and  in  Columbia  it  continued  till 
September  of  the  same  year. 

Two  decades  now  passed  without  the  occurrence  of  dengue  in  extended 
epidemics.  It  is  true  that  in  1839  an  outbreak  took  place  at  Iberville,  in 
Louisiana,  and  one  in  1844  at  Mobile,  but  they  appear  to  have  been  con- 
fined to  the  localities  in  which  they  first  appeared. 

In  the  summer  of  1848,  it  again  showed  itself  in  New  Orleans,  and 
less  extensively  in  Vicksburg  and  Natchez.  In  these  outbreaks,  dengue 
appeared  simultaneously  with  the  yellow  fever.  In  the  autumn  of  the 
same  year  it  was  again  observed  in  Mobile.  Cases  occurred  during  the 
next  two  years,  from  time  to  time,  in  the  cities  along  the  Gulf  Coast. 

In  1850,  a  wide-spread  epidemic  visited  the  Southern  States.  Appear- 
ing in  Charleston  toward  the  end  of  July,  it  spread  successively  to  Sa- 
vannah, Augusta,  Mobile,  New  Orleans,  and  intermediate  points,  and  into 
Texas,  in  which  state  it  became  epidemic  in  October.  The  extent  of 
prevalence  of  this  disease  in  some  of  the  localities  visited  by  this  epi- 
demic is  remarkable.  Dickson  informs  us  that,  in  Charleston,  all  the 
members  of  large  households  were  attacked,  without  a  single  exception, 
and  that  of  his  own  family,  numbering  eleven  persons,  he  alone  escaped. 
It  is  computed  that  ten  thousand  persons  were  ill  in  Charleston  at  one 
period,  and  that  between  seventy  and  eighty  per  cent,  of  the  population 
suffered  during  the  epidemic.  The  number  of  inhabitants  in  the  town  of 
New  Iberia,  Louisiana,  in  1857,  did  not  exceed  two  hundred  and  fifty; 

'  Hirsch :  Handbuch  der  historisch-geographische  Pathologie.     Erlangen,  1860. 


DENGUE.  347 

of  these,  two  hundred  and  ten  contracted  the  disease  during  a  period  of 
six  weeks. 

Less-extended  epidemics  occurred  at  various  points  in  the  same  belt 
of  country  in  1861,  and  again  in  1866. 

In  the  summer  of  18-46,  dengue  appeared  in  Brazil,  and  prevailed 
widely.  It  reappeared,  at  the  same  season  of  the  year,  in  the  three  fol- 
lowing years.  In  1852  it  visited  Peru.  This  visitation  was  followed  by 
yellow  fever. 

In  the  eastern  hemisphere,  from  the  time  of  the  epidemic  reported  by 
Wise,  already  alluded  to,  no  outbreak  is  mentioned  till  1799,  when  it 
broke  out  in  Lower  Egypt,  and  prevailed  extensively  in  and  around 
Cairo,  under  the  name  of  the  "knee  eviL"  Pruner,  who  had  seen  the 
affliction  on  the  coast  of  Arabia  in  1835,  again  encountered  it  at  Cairo, 
in  August,  1845,  and  a  little  later  in  Alexandria.  No  further  accounts 
are  met  with  concerning  the  existence  of  the  disease  in  tropical  Africa 
until  1871.  It  has,  at  various  periods,  prevailed  very  extensively  in 
India;  in  the  year  1824,  dengue  made  its  appearance  as  an  unknown 
disease,  both  to  the  physicians  and  the  public,  in  the  southern  parts;  it 
spread,  in  the  rainy  season,  to  Calcutta,  and  from  there,  along  the  Ganges, 
to  Berhampoor,  whence  it  extended  over  the  southern  portion  of  Bengal 
and  a  part  of  Madras.  In  March,  1825,  it  reappeared  at  Berhampoor, 
and  became  epidemic  in  the  surrounding  country  in  the  rainy  season. 
Again,  in  1836,  the  disease  visited  Calcutta,  and  Pruner  states  that 
travellers,  who  came  from  India  to  Cairo  in  1845,  told  of  its  epidemic 
prevalence  in  that  country  and  along  the  borders  of  the  Red  Sea. 

In  1860,  it  appeared  among  the  ships  at  Martinique,  and  spread  later 
to  the  garrison.  Balbot  states  that,  of  four  hundred  men  constituting 
the  garrison,  one  hundred  and  twelve  suffered  from  the  disease. 

The  dengue  prevailed  in  Spain  from  1864  to  1868. 

It  appeared  in  Arabia  in  1871,  and  was  observed  by  Read,  especially 
in  Mecca,  Medina,  and  Aden.  In  the  last  of  these  cities  it  was  epidemic 
during  a  period  of  more  than  seven  months;  of  the  garrison  of  nine  hun- 
dred men,  seven  hundred  had  the  disease.  Following  the  line  of  travel, 
it  spread,  in  1871,  to  Zanzibar  and  other  points  on  the  African  coast.  It 
was  observed  in  the  same  year  at  Port  Said,  where  it  is  said  to  have  pre- 
vailed every  year  at  the  season  of  the  date-harvest.  In  November,  1871, 
it  broke  out  in  Java.  In  1872,  it  spread  through  all  India,  starting  from 
Bombay  and  Cananore,  and  following,  at  first,  the  line  of  the  railroads. 
Cases  appeared  at  the  same  period  in  the  English  stations  of  China,  Bur- 
mah,  and  NepauL  This  epidemic  was  as  intense  as  it  was  wide-spread. 
In  some  localities  scarcely  an  individual  escaped.  In  Madras  it  prevailed 
so  violently  that  not  a  house  escaped.  The  epidemic  reached  its  height 
in  September  and  October,  and  subsided  suddenly,  after  a  heavy  rain, 
about  the  middle  of  the  latter  month. 


348  THE  CONTINUED  FEVERS. 

A  mild  epidemic  of  dengue  prevailed  at  Charleston  and  in  some  of 
the  neighboring  localities,  and  at  various  points  along  the  Gulf  Coast, 
during  the  summer  and  autumn  of  1880.  It  ceased  with  the  advent  of 
cold  weather  and  frost.  At  the  same  time  this  disease  was  extensively 
prevalent  in  Northern  Egypt. 

Etiology. 

I.    PREDISPOSING   CAUSES. 

There  can  be  no  doubt  whatever  that  climate  has  a  large  influence  in. 
the  development  of  dengue.  It  is  a  disease  of  tropical  and  subtropical 
lands.  When  it  has  occurred  in  colder  countries,  it  has  made  its  appear- 
ance almost  exclusively  in  the  summer  or  autumn,  and  upon  the  advent 
of  cold  weather  has  promptly  disappeared.  Its  prevalence  has  also  been 
restricted  to  sporadic  cases  or  to  circumscribed  local  epidemics.  Arnold  ' 
declares  that  "  this  disease  is  undoubtedly  affected  by  frost.  The  diminu- 
tion of  cases  after  a  frost  last  fall,  was  as  marked  as  the  diminution  of 
cases  in  our  endemic  climate  fever  usually  is." 

With  this  exception  the  concUtioti  of  the  weather  has  no  direct  influ- 
ence either  upon  the  origin  or  upon  the  epidemic  spread  of  the  disease. 
Within  the  tropics  it  has  occurred  alike  in  the  hot,  the  cool  and  the 
rainy  season  of  the  year.  In  our  Southern  States  it  has  prevailed  in  wet 
and  dry,  in  cool  and  warm  weather,  indifferently,  though  it  is  to  be  re- 
marked that  it  has  almost  always  first  broken  out  in  summer  and  disap- 
peared to  a  great  extent,  if  not  wholly,  in  the  winter  months.  In  the  W^est 
Indies  it  prevailed  continuously  for  a  period  of  "nearly  twelve  months 
through  a  variety  of  seasons,  and  was  neither  perceptibly  influenced  by 
vernal  nor  autumnal  equinoxes,  by  our  strong,  wintry  north  wind,  nor  by 
the  scorching,  fiery  sea-breezes  of  June  and  July  "  (Maxwell). 

The  supposition  that  a  peculiar  condition  of  the  atmosphere,  combining 
a  high  degree  of  moisture  and  "  stagnation  of  the  air  "  with  prolonged  and 
very  intense  heat,  are  necessarily  associated  with  the  origin  and  trans- 
mission of  the  disease,  or  that  its  appearance  as  an  epidemic  is  necessarily 
preceded  by  prolonged,  heavy  rains,  falls  to  the  ground,  in  view  of  the 
recorded  fact  of  its  prevalence  at  all  seasons  of  the  year  in  tropical  regions, 
and  its  steady  advance  in  the  direction  of  the  lines  of  human  intercourse 
without  regard  to  the  dryness  or  moisture  of  the  weather. 

Dengue  is  in  the  strictest  sense  a  pandemic  disease.  With  the  excep- 
tion of  influenza,  no  other  disease  has  prevailed  over  so  wide  an  extent  of 
the  surface  of  the  globe,  or  attacked  with  such  impartiality  the  inhabitants 
of  the  countries  over  which  it  has  passed. 

'  Charleston  Medical  Journal,  May,  1851. 


DENGUE.  349 

Hace  and  nationality  hare  but  little  influence  upon  this  disease.  Ob- 
servers in  all  countries  where  it  has  prevailed  agree  in  the  statement  that 
it  spreads  equally  among  the  white  and  colored  of  all  nations.  To  this 
general  remark  must  be  made  the  exceptions,  that  in  the  South  the  negro 
race  is  attacked  a  little  later  and  suffers  less  generally  than  the  whites, 
and  that,  in  the  last  epidemic  in  India,  Europeans  recently  arrived  ap- 
peared to  suffer  from  the  disease  in  a  milder  form  than  residents  already 
acclimated. 

The  disease  spares  neither  age,  sex,  nor  occupation.  Infants  in  arms 
and  octogenarians  are  equally  prone  to  it.  All  classes  of  society  alike 
suffer.  The  physician  enjoys  no  immunity.  He  is  almost  invariably  at- 
tacked. Aitken  suggests  that  this  is  the  reason  that  the  details  of  symp- 
toms in  epidemics  of  this  disease  are  so  minute. 

It  prevails,  as  a  rule,  chiefly  in  cities,  less  generally  in  the  open  coun- 
try.     To  this  there  have  been,  however,  notable  exceptions. 

n.  THE  KxcrriNG  cause. 

The  exciting  cause  of  the  disease  is  unknown.  That  it  is  specific  is 
no  longer  open  to  doubt.  Whether  it  is  strictly  a  contagium  or  a  miasm 
is  still  undecided.  It  is  capable  of  being  conveyed  by  human  intercourse, 
and  in  most  instances  has  spread  by  a  steady  progress,  in  direct  lines  from 
the  points  of  early  infection.  Dickson  and  some  of  the  observers  of  the 
later  Indian  epidemic  look  upon  the  disease  as  contagious,  but  adduce  no 
direct  proofs;  others  strongly  oppose  this  view.  Most  physicians  who 
have  had  the  opportunity  of  personally  observing  the  disease  express  no 
opinion  upon  this  point.     It  is  not  generally  regarded  as  contagious. 

Its  mode  of  invasion,  its  rapid  march,  the  unsparing  manner  in  which 
it  attacks  entire  families,  cities,  and  even  districts  within  a  brief  space  of 
time,  are  opposed  to  the  assumption  that  it  is  propagated  by  contagion 
alone. 

In  some  of  the  outbreaks,  dengue  has  preceded  or  followed  yellow 
fever.  But  it  has  so  often  occurred  independently  of  any  association  with 
that  disease,  that  the  existence  of  any  pathological  relationship  is  in  the 
highest  degree  improbable.  Dengue  has  not  only  prevailed  in  the  mari- 
time countries  subject  to  yellow  fever,  but  it  has  extended  to  the  moun- 
tainous back-country,  in  which  the  latter  fever  is  unknown.  The  occasional 
association  of  dengue  with  scarlet  fever  and  whooping-cough  in  epidemics 
is  accidental,  not  causal. 

No  hypothesis  adequate  to  explain  the  fierce  epidemic  outbreak  of 
this  disease  in  widely  separated  localities,  and  at  long  intervals  of  time, 
has  yet  been  advanced. 


350  THE  CONTINUED  FEVERS. 


Clinical  History. 

The  period  of  incubation  in  about  lialf  the  cases  is  extremely  brief. 
At  the  commencement  and  at  the  maximum  of  an  epidemic,  the  attack  may 
follow  exposure  in  a  few  hours,  occurring  without  preliminary  symptoms. 
Toward  the  close  of  an  epidemic,  the  period  which  elapses  between  the 
exposure  and  the  onset  of  the  attack  may  be  lengthened  to  several  days. 

The  invasion  of  the  disease  is  generally  abrupt;  there  may  in  some 
cases,  however,  be  a  prodromal  stage  of  from  one  to  three  days,  charac- 
terized by  lassitude,  headache,  a  furred  tongue,  loss  of  appetite,  muscular 
soreness,  and  chilliness. 

Usually,  however,  the  patient  is  seized,  upon  waking,  with  intense 
headache,  burning  pain  in  the  temples,  backache,  and  severe  pain  in  the 
joints.  Sometimes  the  first  symptom  is  an  acute  pain  in  one  of  the  joints — 
for  example,  one  of  the  joints  of  the  hand  or  foot;  this  may  come  on 
while  the  patient  is  engaged  at  his  ordinary  occupation,  and  apparently  in 
full  health. 

The  affected  joints  rapidly  become  swollen,  and  the  skin  of  the 
face  and  neck  is  flushed  and  turgid.  Painful  stiffness  of  the  muscles  fol- 
lows; the  affected  members  are  moved  with  great  difficulty  and  suffer- 
ing. The  muscles  of  the  eyes  sometimes  become  stiff  and  immovable,  the 
conjunctiva  reddened,  the  eyelids  swollen,  so  that  the  patient  wears  a 
staring  expression,  while  the  eyeballs  feel  too  large  for  the  sockets. 
There  is  intolerance  of  light  and  sound.  At  the  same  time  symptoms  of 
gastric  disturbance  occur;  the  tongue  is  coated;  a  burning  pain  is  felt 
in  the  epigastrium,  and  there  is  nausea,  followed  by  bilious  vomiting. 
The  irritability  of  the  stomach  is  often  so  great  that  scarcely  anything  is 
retained.  In  most  cases  desire  for  food  is  wholly  lost;  but  not  infre- 
quently, especially  in  children,  the  appetite  is  retained;  thirst  is  not  ur- 
gent; the  bowels  are  constipated. 

Fever  makes  its  appearance  at  the  onset  of  the  attack,  and  reaches 
its  height  within  the  first  twenty-four  hours.  A  temperature  of  41.5°  C. 
or  42°  C.  (106.7°  F.  or  107.G°  F.)  is  not  infrequently  observed  in  the 
axilla.  The  fever  is  now  continuous  ;  the  pulse  is  full,  hard,  strong 
and  exceedingly  frequent,  beating  from  120  to  140,  and  even  higher 
in  children.  The  breathing  is  quickened,  the  skin  hot  and  dry.  Confu- 
sion of  thought,  and  even  delirium,  particularly  in  children,  also  occur, 
and  in  j^oung  children  the  disease  sometimes  commences  with  convul- 
sions. There  are  no  other  symptoms  primarily  referable  to  the  nervous 
system. 

In  a  great  majority  of  the  cases,  an  exanthem  of  variable  character 
now  shovFS  itself.    This  eruption  most  frequently  resembles  the  efflorescence 


DENGUE.  351 

of  scarlatina,  and  for  this  reason  dengue  was  regarded  by  many  of  the 
older  observers  as  an  epidemic  scarlatinal  rheumatism. 

The  duration  of  the  first  febrile  paroxysm  is  variable,  lasting  from  a 
few  hours  to  several  days.  Its  average  duration  is  from  two  to  three 
days.  The  fever  generally  abates  suddenly,  often  with  the  occurrence  of 
critical  discharges,  such  as  profuse  sweats,  epistaxis,  or  diarrhoea,  the 
evacuations  being  dark,  greenish,  tawny,  and  foul-smelling. 

Exceptionally  the  fever  subsides  slowly  by  lysis.  The  subsidence  of 
the  fever  is  marked  by  the  disappearance  of  the  eruption,  if  any  be  pres- 
ent, by  the  appearance  of  moisture  on  the  skin,  and  an  amelioration  of  the 
pains  in  the  muscles  and  joints.  In  most  cases  the  patient,  although  much 
relieved,  is  unable  to  leave  his  bed  by  reason  of  the  great  prostration  fol- 
lowing the  fever.  In  other  cases  the  relief  is  so  great  and  the  strength 
so  well  preserved,  that  the  patients  do  not  hesitate  to  arise  from  bed  and 
even  to  leave  the  chamber. 

This  stage  of  the  disease,  which  is  analogous  to  the  intermission  of 
relapsing  fever,  is  thought  by  recent  observers  to  be  in  most  cases  a  very 
marked  remission,  in  Avhich  the  temperature  closely  approaches,  but  does 
not  reach,  the  normal;  in  others  it  amounts  to  a  period  of  complete  apy- 
rexia.  Its  duration  is  from  two  to  three  days.  In  some  cases  it  is  wanting 
altogether,  or  of  so  short  duration  that  it  is  overlooked.  Notwithstanding 
the  great  amelioration  of  all  the  symptoms  during  this  period,  some  head- 
ache, and  more  or  less  of  the  stiffness  of  the  joints  and  muscles,  remain. 
At  the  expiration  of  some  hours,  or  of  two  or  three  days,  as  the  case  may 
be,  acute  symptoms  reappear  and  the  second  febrile  paroxysm  sets  in. 
Fever  again  arises,  but  it  is  not  so  intense  as  before,  and  its  type  is  re- 
mittent rather  than  continued.  The  tongue  again  becomes  coated,  appe- 
tite is  lost,  nausea  distresses  the  patient,  but  vomiting  at  this  stage  is 
rare.  Headache  attends  it,  and  in  many  cases  there  is  an  exacerbation  of 
the  pains  in  the  joints  and  some  increase  in  the  stiffness  of  the  muscles, 
both  these  symptoms  having  continued  in  some  degree  throughout  the  re- 
mission. Coincidently  with  the  reappearance  of  the  fever,  an  eruption 
shows  itself.  This  eruption,  which  may  be  looked  upon  as  the  distin- 
guishing feature  of  the  second  paroxysm  of  the  disease,  has  been  variously 
described  by  different  observers  as  erythematous,  reseola-like,  rubeolous, 
or  as  resembling  urticaria.  Appearing  in  many  instances,  first  upon  the 
palms  of  the  hands  or  upon  the  soles  of  the  feet,  it  extends  over  the 
greater  part  of  the  surface  of  the  body.  Or  it  may  be  localized  in  certain 
regions.  It  is  attended  by  annoying  itching,  and,  after  an  existence  vary- 
ing from  some  hours  to  two  or  three  days,  it  vanishes  and  is  followed  by 
furfuraceous  desquamation. 

The  duration  of  these  symptoms  is  usually  about  two  or  three  days. 
The  fever  gradually  subsides,  and  the  acute  symptoms  disappear,  leaving 
the  patient  in  an  enfeebled  state,  often  requiring  months  for  the  re-estab- 


352  THE    CONTINUED    FEVERS. 

lishment  of  health.  Besides  the  debility,  which  is  often  very  great, 
emaciation,  diarrlioea,  and  painful  stiffness  and  swellings  of  the  joints,  pro- 
tract the  convalescence. 

Complications  do  not  occur,  and  there  are  no  sequels.  Relapses  often 
take  place,  and  occasionally  repeated  relapses  befall  the  same  patient. 
They  run  a  milder  course  than  the  primary  attack.  The  affection  is  scarcely 
ever  fatal.  Convulsions  may  occasion  an  unfavorable  termination  in 
infants.  On  the  other  hand,  it  is  among  the  most  painful  of  the  epidemic 
diseases,  and  not  seldom  gives  rise  to  serious  impairment  of  health  by 
the  exhaustion  which  follows  the  high  fever,  the  prolonged,  severe  pains, 
the  sleeplessness,  the  inability  to  retain  food,  and  the  abundant  critical 
discharges. 

The  course  of  the  disease  may  be  divided  according  to  recent  ob- 
servers into — 

a,  the  period  of  first  febrile  access,  two  to  three  days. 

h,  the  intermission,  some  hours  to  two  or  three  days. 

c,  the  second  febrile  stage,  two  to  three  days. 

Whole  duration  of  the  acute  symptoms,  about  eight  days. 

The  intermission  may  be  altogether  absent. 

The  duration  of  epidemics  varies  from  two  to  seven  months. 

It  remains  to  consider  more  in  detail  some  of  the  prominent  symp- 
toms. 

Tlie  affection  of  the  joints  and  limbs,  which  accompanies  the  first 
paroxysm,  gives  rise  to  the  peculiarities  of  gait  and  attitude  which  are 
expressed  in  so  many  of  tlie  popular  names  of  the  disease.  It  attacks 
large  and  small  joints  alike,  often  six  or  eight  being  affected  at  once. 
The  joints  of  the  hand,  foot,  and  knee,  the  spine,  the  fingers,  the  toes, 
the  elbow  and  shoulder,  are  ofttimes  involved  successively  in  the  order 
given.  In  severe  cases  all  the  joints  are  implicated  (Zuelzer),  The  joints 
are  swollen,  red,  immobile,  painful,  and  often  exquisitely  sensitive  to  the 
touch.  The  stiffness  of  the  affected  limbs  is  not  Avholly  due  to  the  condi- 
tion of  the  joints.  The  muscles  are  likewise  stiffened  and  sore,  and  there 
is  an  effusion  of  serum  in  the  connective  tissue  surrounding  certain  of  the 
tendons.  The  finsrers  are  often  stiff,  and  the  hand  cannot  be  closed.  This 
is  particularly  the  case  in  the  morning,  and  constitutes  an  annoying  cir- 
cumstance of  the  convalescence. 

The  pains  are  described  as  rheumatic  or  rheumatoid,  by  most  writers. 
De  Wilde  observed  isolated  painful  spots  in  several  instances,  and  in 
others  found  a  single  nerve-trunk,  as  the  ulnar,  to  be  affected.  The 
pains  in  this  disease,  as  in  acute  articular  rheumatism,  pass  from  one  set 
of  joints  to  another  with  remarkable  rapidity.  At  the  onset  of  the  attack, 
only  severe  headache  and  pain  in  the  hands  may  be  complained  of,  yet  in 
a  few  hours  the  joints  of  the  feet  and  the  knees  may  have  become  in- 
volved.    Each  new  invasion  of  a  part  is  accompanied  in  such  instances 


DENGUE.  353 

by  twitching  of  the  muscles  in  the  neighborhood  of  the  joint  affected 
(Aitken).'  Patients  describe  the  pains  as  of  exceeding  severity  ;  they 
express  them  by  such  terms  as  "  boring  "  and  "  breaking."  Few  can  en- 
dure them  without  complaining.  This  affection,  much  less  prominent 
during  the  second  paroxysm  of  the  fever  than  in  the  first,  gradually  disap- 
pears; but  it  may  persist  for  several  weeks,  or  even  for  some  months, 
becoming  fixed  in  one  or  more  joints. 

In  three  cases  examined  after  death,  serous  infiltration  of  the  connec- 
tive tissue  in  the  neighborhood  of  affected  joints  was  found  twice,  and 
reddening  of  the  crucial  ligament  of  the  knee  once  (Hirsch). 

As  has  already  been  pointed  out  in  the  definition  of  the  disease,  z.  pri- 
mary and  a  secondary  exanthem,  corresponding  respectively  to  the  first 
and  second  febrile  paroxysms,  occur  in  a  majority  of  the  cases. 

The  first,  though  present  in  a  large  proportion  of  the  cases,  is  by  no 
means  constant.  When  present  it  appears  and  disappears  coincidently 
with  the  fever. 

The  latter  is,  as  a  rule,  always  encountered.  Much  diversity  of  vie-w 
as  to  the  character  of  this  eruption  is  found  in  the  writings  of  those  who 
have  recorded  their  personal  observations  of  the  disease.  The  forms  com- 
monly assumed  by  the  eruption  have  already  been  indicated.  In  some  in- 
stances they  are  mixed,  as,  for  example,  erythema  and  urticaria  may  be 
present  at  the  same  time.  Urticaria  is  common  in  children.  Consider- 
able swelling  of  the  skin  attends  the  appearance  of  this  eruption  in  some 
regions,  especially  upon  the  palms  and  soles,  at  the  lobe  of  the  ear,  and 
about  the  eyes,  where  it  induces  conjunctivitis  and  lachrymation.  In  se- 
vere cases  the  mucous  m,embrane  of  the  mouth  and  throat,  and  that  of  the 
nostrils,  is  inflamed.  Aphthous  ulcerations  occur  upon  the  tongue  and 
buccal  mucous  membrane.  The  secretion  of  saliva  is  sometimes  increased, 
and  the  salivary  glands,  and  in  particular  the  parotids,  are  swollen. 

The  superficial  lymphatics,  about  the  angle  of  the  jaw  and  in  the  groin, 
are  also  in  some  instances  transiently  enlarged.  Less  commonly,  boils  oc- 
cur during  the  convalescence,  and  some  observers  have  recorded  the  occa- 
sional occurrence  of  extensive  subcutaneous  abscesses. 

The  desquamation  is  usually  bran-like,  but  this  is  not  always  the  case. 
The  epidermis  has  been  observed  to  peel  off  in  large  flakes,  leaving  a 
denuded,  painful  surface,  which  has  sometimes  resulted  in  superficial  ul- 
cerations. The  urine  during  the  access  of  fever  is  scanty  and  of  dark 
color;  its  specific  gravity  is  high;  albumen  has  not  been  observed.  With 
the  crisis  its  quantity  is  augmented. 

Restlessness,  sleeplessness,  headache,  especially  involving  the  forehead 
and  temples,  and  sometimes  nocturnal  delirium,  attend  the  fever. 

'  Reynolds'  System  of  Medicine.     Article  on  Dengue.     Vol.  i.,  1868. 


354  THE  CONTINUED  FEVERS. 

In  children  the  fever  is  of  shorter  duration,  and  the  course  of  the  dis- 
ease is  modilied  by  the  convulsions  by  which  its  advent  is  not  seldom 
heralded,  and  which  sometimes  persist,  and  even  lead  to  a  fatal  issue. 
Hapid  emaciation,  and,  as  has  been  pointed  out,  an  extreme  debility, 
attend  this  disease.  Weakness  and  loss  of  muscular  power,  in  the  legs 
especially,  often  continue  far  into  the  convalescence. 

Hirsch  informs  us  that  affections  of  the  heart  appear  to  have  been  in 
no  case  encountered.  His  opinion  is  the  result  of  a  study  of  the  histories 
of  the  epidemics  prevailing  previous  to  1860.  In  the  recent  epidemics  in 
India,  M.  Sheriff  and  Dunkley  not  seldom  observed,  after  the  fever,  an 
affection  of  the  heart,  which  was  considered  to  be  pericarditis.  In  no  case 
did  it,  however,  result  in  death,  and  after  a  time  it  disappeared  (Zuelzer). 

The  respiratory  organs  are  not  implicated  in  the  disease.  In  very 
rare  instances  pleurisy  has  been  noted.  It  is  probable  that  its  association 
with  dengue  in  such  cases  was  accidental. 

It  is  stated  by  observers  of  the  West  Indian  epidemics,  that  females 
at  various  periods  of  pregnancy  suffered  the  severer  forms  of  the  fever 
without  any  tendency  to  abortion.  But,  in  the  visitation  in  India  in  1872, 
this  accident  not  infrequently  took  place. 

Dr.  F.  P.  Porcher  furnished  to  the  National  Hoard  of  Health  Bul- 
letin, September  25,  1880,  the  following  account  of  the  mild  epidemic  of 
break-bone  fever  which  prevailed  during  the  past  summer  at  Charleston: 

"  It  began,  it  appears,  in  the  extreme  northwestern  portion  of  the  city, 
above  Calhoun,  near  Line  and  Columbus  streets,  in  what  was  formerly 
called  the  '  Neck.'  Afterward  it  seemed  to  progress  into  the  lower  or 
oldest  part,  and  there  is  every  indication  that  it  is  now  diminishing. 

"  The  earth  had  been  disturbed  in  the  paving  of  King  street,  an  exten» 
sive  thoroughfare  running  north  and  south  the  entire  length  of  the  city, 
and  the  special  section  of  the  city  where  the  first  cases  were  noticed  was 
not  in  as  good  a  condition  as  others,  being  near  the  marshes,  and  new 
streets  having  been  opened  there;  but,  though  we  were  at  first  inclined 
to  search  for  the  causes  of  disease  in  these  conditions,  the  simultaneous 
appearance  of  the  fever  in  the  West,  and,  as  we  learn,  in  Savannah  and 
Augusta,  must  exclude  such  a  supposition,  and  refer  it  to  general  and 
wide-prevailing  atmospheric  influences. 

"Besides  our  own  experience,  which  has  been  limited  on  account  of 
temporary  absence,  we  have  made  diligent  inquiries  of  many  persons,  of 
physicians  as  well  as  the  laity,  and  learn  the  following  particulars,  which 
we  present  in  default  of  a  more  complete  report,  which  will  doubtless  be 
made  in  the  future. 

"  The  symptoms  vary  exceedingly — some  being  present  and  some  ab- 
sent— as  follows:  the  disease  generally  begins  with  a  feeling  of  coldness, 
or  by  a  chill,  followed  by  fever;  this,  with  a  temperature  ranging  from 
100°  to  105°,  lasts  generally  from  twenty-four  to  forty-eight  hours,  occa- 


DENGUE.  355 

sionally  extending'  to  four  or  five  days,  and  even  In  rare  cases  to  seven. 
Relapses  occasional,  especially  in  those  who  have  gone  out  too  early. 
Headache  frequent,  generally  frontal,  from  the  beginning.  Miliary  erup- 
tions, sometimes  elevated  and  red,  like  measles,  and  the  occasional  pres- 
ence of  sudamina  over  the  face,  neck,  aixdhody  ;  sometimes  the  eruptions 
were  confined  to  the  body,  and  endured  for  days  after  recovery.  We 
have  seen  some  examples  of  slight  desquamation — furfuraceous  or  branny 
in  character.  Sweating  profuse  in  many  persons,  though  often  absent. 
Hence,  some  physicians  are  inclined  to  consider  the  disease  to  be  suette 
miliare  of  a  mild  form.  '  Break-bone  '  is  the  best  name,  because  pain  in 
the  bones  and  limbs  is  the  most  constant  symptom.  There  is  often  great 
restlessness  during  the  fever,  and  in  some  a  feeling  of  tightness  or  con- 
gestion about  the  throat,  with  bleeding  in  a  few  cases  known  to  us.  Ca- 
tarrhal symptoms  are  rarely  present,  although  cough  has  occasionally 
existed.  Bleeding  from'the  nose  not  unusual  in  children,  and  also  increase 
in  the  menstrual  molimen  has  been  observed.  Pain  in  the  back  and  limbs 
markedly  present,  but  no  decided  swelling  of  joints,  no  carbuncular  en- 
largements or  boils,  as  in  the  epidemic  of  dengue  of  forty  years  since,  or 
in  that  of  '  break -bone'  which  followed  some  years  subsequently.  Weak- 
ness and  prostration  have  been  very  decided,  but  not  nearly  to  such  an 
extent  as  in  previous  epidemics.  Some  of  the  physicians  consider  that 
there  has  been  a  tendency  to  hepatic  torpor  or  congestion — of  no  great 
severity,  however.  We  have  heard  of  no  cases  of  decided  jaundice.  Nau- 
sea and  vomiting  seldom  occur. 

"  The  disease  does  not  affect  all  the  members  of  a  household,  often- 
times only  one  or  two  being  seized,  though  we  have  known  six  to  be 
taken  in  one  house;  in  this  respect  differing  from  the  dengue,  as  described 
by  Prof.  Dickson,  and  from  the  epidemic  seen  by  us  some  thirty  years 
since.  Then  ten  thousand  were  down;  no  one  was  well  enough  or  strong 
enough  to  help  his  neighbor,  and  one  had  to  learn  to  walk  over  again. 

"  It  is  difficult  to  calculate  the  number  who  have  suffered,  as  very 
many  have  not  employed  a  physician;  from  two  to  three  thousand,  per- 
haps, approximates  the  number. 

"  Very  little  active  treatment  has  been  used — as  far  as  we  can  learn,  as 
follows:  a  mild  laxative,  saline  or  mercurial,  hot  teas,  nitre,  pediluvia, 
sinapisms,  etc.,  and  quinine  during  and  after  the  attack,  upon  theoretical 
grounds,  with  occasionally  mild  stimulants.  Several  persons  have  recov- 
ered with  no  treatment  whatever. 

"  It  has  prevailed  among  both  races,  perhaps  equally,  and  not  a  single 
death  is  ascribed  to  this  disease,  as  far  as  we  can  learn.  The  only  disad- 
vantage which  accrues  to  those  who  take  it  is  the  time  lost,  and  the  tem- 
porary pain  and  weakness  from  which  they  suffer. 

"  Persons  who  were  in  the  city  and  who  visited  the  country  had  mild 
attacks.     We  know  of  four  such;  one  of  these  had  reached  Asheville, 


356  THE  CONTINUED  FEVERS. 

N.  C,  where  we  saw  him.  Cases  of  the  fever  have  occurred  in  Summer- 
ville,  thirty  miles  off,  on  the  line  of  the  South  Carolina  Railroad,  among 
persons  who  had  never  visited  the  city;  others  sickened  there  who  had 
paid  flying  visits,  remaining  a  part  of  a  day  only." 

Diagnosis. 

Tlie  diagnosis  is  not  attended  with  difficulty.  No  other  disease  pre- 
senting analogous  symptoms  spreads  with  the  same  rapidity  through  a  com- 
munity. No  other  disease  whatever,  except  influenza — with  which  dengue 
can  by  no  possibility  be  confounded — attacks  entire  communities,  sparing 
neither  the  young  nor  the  old,  the  poor  nor  the  rich,  and,  as  has  more 
than  once  been  recorded,  not  a  single  individual  in  a  district. 

The  natural  history  of  dengue  makes  it  unnecessary  to  point  out  the 
points  of  differential  diagnosis  between  it  and  acute  articular  rheumatism, 
to  which  it  presents,  in  the  first  febrile  paroxysm,  strong  resemblances  ;  or 
between  it  and  scarlet  fever  or  measles,  which  the  eruptions  of  the  second 
paroxysm  are  said,  in  certain  instances,  to  resemble.  Its  likeness  to  re- 
lapsing fever  is  confined  to  its  course,  which  is  in  fact  that  of  a  relapsing 
fever.  In  future  outbreaks  careful  microscopic  examinations  of  the  blood 
are  urgently  called  for,  in  view  of  this  resemblance,  and  the  discovery  by 
Obermeier  of  a  minute  organism  in  the  blood  of  relapsing  fever  patients. 


Treatment. 

Efficient  methods  oi  prophylaxis,  as  regards  the  individual  in  infected 
localities,  are  not  known.  As  rega,rds  communities,  it  has  been  recom- 
mended that  a  rigid  quarantine  of  the  districts  in  which  dengue  prevails, 
and  the  isolation  of  the  patients,  may  prevent  its  spreading.  These  mea- 
sures, in  view  of  the  march  of  epidemics  along  the  lines  of  human  inter- 
course, the  facility  of  its  transportation  in  ships,  and  the  enormous  aggre- 
gate of  human  suffering  which  its  unchecked  progress  occasions,  will 
demand  vigorous  enforcement  by  the  authorities  of  the  city  or  region  in 
"which  dengue  shall  next  make  its  appearance. 

There  is  no  abortive  treatment. 

It  is  a  specific  disease,  for  which  we  possess  no  specific  remedy. 
Nevertheless,  much  can  be  done  by  a  judicious  medication  to  mitigate  the 
symptoms  and  abridge  the  period  of  convalescence.  The  treatment  is  to 
be  conducted  in  accordance  with  general  therapeutic  principles,  and  is  for 
the  most  part  symptomatic. 

Neither  general  nor  local  blood  letting  is  of  service.  Either  increases 
the  tendency  to  debility  and  gives  rise  to  vertigo  during  the  convalescence, 
which  is,  at  the  same  time,  protracted. 


DENGUE.  357 

Eliminative  measures,  in  accordance  with  the  practice  of  the  tropics, 
have  usually  been  employed  in  the  beginning  of  the  treatment. 

Emetics  are  highly  spoken  of.  In  several  epidemics,  pushed  to  the 
production  of  free  bilious  vomiting,  they  have  greatly  relieved  the  head 
and  eased  the  pains.  For  this  purpose  tartarized  antimony  and  ipecacu- 
anha were  used.     The  latter  is  to  be  preferred. 

Purgation  is  called  for  by  the  constipation  which  exists  during  the 
first  period  of  fever,  and  by  the  dark  green  color  and  highly  offensive 
character  of  the  evacuations  which  commonly  take  place  at  its  critical 
termination.  It  is  desirable  to  anticipate  elimination  by  the  bowels  by 
recourse  to  mild,  but  efficient  purgatives.  The  disappearance  of  the 
green  color  and  the  occurrence  of  more  natural  fecal  discharges,  has  co- 
incided with  a  further  amelioration  of  the  symptoms.  It  is  not  neces- 
sary to  push  pui-gation  to  the  bringing  about  of  watery  discharges. 
Rhubarb,  aloes,  magnesium  sulphate,  and  the  like,  variously  associated 
and  combined,  are  proper  remedies.  The  aggravation  of  the  sufferings  of 
the  patient  which  attends  the  act  of  defecation  cannot  be  rei^arded  as  a 
contraindication  to  their  use,  in  view  of  the  concurrent  testimony  of  al- 
most all  observers  that  they  are  of  undoubted  service.  The  bowels 
should  be  kept  open  throughout  the  sickness  by  the  occasional  adminis- 
tration of  mild  laxatives. 

With  a  view  of  acting  upon  the  sMn,  the  sweet  spirits  of  nitre,  neu- 
tral mixture,  or  the  effervescing  draughts  maybe  regularly  given  at  inter- 
vals of  two  or  three  hours.  Warm  baths  have  also  been  employed. 
Bartholow  '  suggests  that,  as  the  first  paroxysm  usually  terminates  by 
crisis  and  commonly  with  sweating,  the  "  behavior  of  nature  "  may  be 
imitated,  and  this  stage  possibly  shortened  by  the  administration  of  pilo- 
carpine. 

If  necessary,  diuretics  are  to  be  administered  along  witli  the  foregoing 
remedies. 

Opiates,  to  relieve  the  pain,  restlessness,  and  inability  to  sleep,  form 
an  important  part  of  the  treatment.  The  subcutaneous  injection  of  mor- 
phia will  in  most  instances  best  fulfil  this  indication.  Dover's  powder 
may  be  given  at  night. 

Belladonna  in  large  doses  has  been  highly  extolled  as  favorably  influen- 
cing the  joint-pains.  Its  local  application  to  the  painful  joints,  in  the  form 
of  a  soft  ointment,  would  probably  constitute  a  valuable  adjunct  to  the 
treatment.  Salicylic  acid  and  the  salicylates,  as  yet  untried  in  this  dis- 
ease, would  also  probably  prove  useful  against  the  rheumatoid  phenomena. 

Alcoholic  stiratdants  should  be  given  from  the  decline  of  the  initial 
fever,  in  carefully  regulated  doses,  regard  being  had  to  the  habits  and 
mode  of  life  of  the  individual  patient. 

'  Practice  of  Medicine,  1880. 


358  THE  CONTINUED  FEVERS. 

Quinine,  combinations  of  iron  with  strychnia,  and  particularly  the 
tincture  of  the  chloride  of  iron,  or  that  preparation  of  it  known  as  Bash- 
am's  mixture,  are  to  be  given  upon  the  subsidence  of  the  fever  of  the 
second  paroxysm.  The  impaired  appetite  and  enfeebled  digestion  are 
best  managed  by  minute  doses  of  strychnia,  0.0015 — 0.001  gramme  (gr. 
■^-^ — gV  ^-  ^')}  either  alone  or  in  combination  with  dilute  phosphoric  acid, 
and  with  or  without  iron. 

The  itching  which  is  so  distressing  a  symptom  in  the  second  paroxysm, 
and  during  the  desquamation  which  supervenes,  may  be  in  part  relieved 
by  the  application  of  lotions  of  ammonium  chloride  and  corrosive  sub- 
limate in  almond  emulsion: 

'^.    Ammonii  chloridi 1 — 1.3  grm.  gr.  xv. — xx. 

Hydrargiri  chloridi  corr...    0.008 — 0.016  grm.  gr. -^  —  ^. 

Misturse  amygdalse 32  c.c.  fl.  §  j. 

M. 

or  a  solution  of  carbolic  acid,  one-half  of  one  per  cent,  to  one  per  cent. 
The  lingering  stiffness,  pain,  and  soreness  of  the  muscles  and  joints  are 
best  treated  by  systematic  hot  douches  and  massage,  and  by  mild  galvanic 
currents. 


INDEX. 


Abscess,  hepatic,  in  typhoid  fever,  185 
of  the  spleen  in  relapsing  fever,  333 
Abscesses,  in  relapsing  fever,  333 
in  typhoid  fever,  189 
multiple,  in  cerebro-spinal  fever,  90 
Adenopathie  bronchique,  in  influenza,  34 
Age,  in  etiology  of  cerebro-spinal  fever,  59 
in  etiology  of  typhoid  fever,  118 
in  etiology  of  typhus  fever,  253 
influencing  the   mortality  in  typhoid 
fever,  219 
Albuminuria,  transitory,  in  typhoid  fever, 

188 
Alcohol,  excess  of,  in  etiology  of  typhus, 
253 

in  typhoid  fever,  226,  299 
Alcoholism,  diagnosticated  from  typhus  fe- 
ver, 297 
Anaemia,  after  relapsing  fever,  333 
Anaesthesia,  •  cutaneous  and   muscular,  in 
typhoid  fever,  167 
in  cerebro-spinal  fever,  77 
Arachnoid,  condition  of,  in  cerebro-spinal 

fever,  91,  93 
Arteries,  fatty  degeneration  of,  in  typhoid 
fever,  208 

Bed-sores,  in  typhoid  fever,  189,  240 

in  typhus  fever,  286 
Blood,  changes  in,  in  typhoid  fever,  208 

condition  of,   in  cerebro  spinal  fever, 
90 
Boils,  in  typhoid  fever,  189 

in  typhus  fever,  285 
Bowels,    hemorrhage    from,     in    typhoid 

fever,  174 
Brain,  changes  in,  in  typhoid  fever,  209 


Brain,  condition  of,  in  cerebro-spinal  fever, 
93 
condition   of   the    dura   mater  of,    iu 

cerebro-spinal  fever,  91 
condition  of  the  substance  of,  93 
Bronchitis,  capillary,  as  a  complication  of 
influenza,  33 

in  relapsing  fever,  333 
in  typhus  fever,  281,  284 

Calvarium,    condition    of,    in    cerebro- 
spinal fever,  91 
Cancrum  oris,  in  typhus  fever,  287 
Catarrh,  bronchial,  in  typhoid  fever,  176, 
181 

the,  of  influenza,  30 
Cellulitis,  in  typhus  fever,  286 
Cerebro-spinal  fever  (see  Fever),  46 
Chill,  in  cerebro-spinal  fever,  73 
Choroiditis,  a  sequel  of  relai^sing  fever,  334 
Circulation,  in  influenza,  29 

in  simple  continued  fever,  5 
Circulatory   system,    symptoms    referable 

to,  in  typhoid  fever,  101 
Climate,     in    etiology     of    cerebro-spinal 
fever,  57 

in  etiology  of  relapsing  fever,  309 
in  etiology  of  typhoid  fever,  116 
in  etiology  of  typhus  fever,  251 
Cold,  antipyretic  use  of,  in  typhoid  fever, 
229 

as  an  antipyi'etic  in  typhus  fever,  298 
Coma,  in  cerebro-spinal  fever,  74 

in  relapsing  fever,  334 
Coma  vigil,  366 

Congestion,  hypostatic,  in  typhoid   fever, 
239 


160 


INDEX. 


Constipation,  in  typhoid  fever,  237 

in  typhus  fever,  283 
Contagium  vivum,  of  t3'phoid  fever,  121 
Convulsions,  in  cerebrospinal  fever,  75 

in  tyijhoid  fever,  165 

in  typhus  fever,  208 
Cornea,  perforation  of,  in  typhus  fever,  287 
Cough,  the,  of  influenza,  31 
Countenance,  in  influenza,  30 
,  Cutaneous  lesions,  in  cerebro-spinal  fever, 

77 
Cystitis,  in  typhoid  fever,  188 

Deaf-mutism,  after  cerebro-spinal  fever, 

89 
Deafness,  after  cerebro-spinal  fever,  89 

in  typhoid  fever,  191 

in  typhus  fever,  287 
Death,  mode  of,  in  cerebro-spinal  fever,  98 
Debility,  in  influenza,  32 

in  relapsing  fever,  325 

in  typhus  fever,  2G7 
Deglutition,  difBcult  in  typhoid  fever,  184 

difficult  in  typhus  fever.  282 
Delirium,  in  cerebro-spinal  fever,  73 

in  relapsing  fever,  324 

in  typhoid  fever,  164,  23.*) 

in  typhus  fever,  265,  300 
Dengue,  344 

clinical  history  of,  350 

diagnosis  of,  356 

etiology  of.  348 

exciting  cause  of,  349 

historical  sketch  of,  345 

treatment  of,  356 
Diarrhoea,  a  complication  and  sequel,  of  re- 
lapsing fever,  333 

in  typhoid  fever,  173,  236 
Diet,  in  typhoid  fever,  225 
Dietetics,  of  typhoid  fever,  222 
Digestive   system,  condition   of,  in  simple 
continued  fever,  5 

derangement  of  the  organs  of,  in  cere- 
bro-spinal fever,  84 

in  influenza,  30 

symptoms   due    to  disturbance  of,  in 
relapsing  fever,  331 

symptoms    referable    to,    in    typhoid 
fever,  170 
Diphtheritic  processes,  in  typhoid  fever,  184 
Drmking-water,  contamination   of,  in  eti- 
ology of  typhoid  fever,  184 


Duodenum,  changes  in,  in    typhoid  fever, 

203 
Dura  mater  of  the  brain,  condition  of,  in 
cerebro-spinal  fever,  91 

condition  of,  in  typhoid  fever,  209 
Dysentery,  a  sequel  of  relapsing  fever,  334 

in  typhus  fever,  287 
Dyspnoea,  the,  of  influenza,  31 

Ear,  disorders  of,  in  cerebro-spinal  fever, 
86 

disorders  of,  in  influenza,  35 
disorders  of,  in  typhoid  fever,  106,  191 
Ecchymoses,  subpleural,  in  tj'phus  fever, 

294 
Effusions  of  blood,  in  typhoid  fever,  189 
Emaciation,  in  dengue,  354 
Endocarditis  and  pericarditis,  in  typhoid 

fever.  184 
Endocarditis,  vi'ith  cerebro-spinal  fever,  91 
Enteric  fever  (see  Fever),  107 

distinguished  from  cerebro-spinal  fe- 
ver, 95 
Enteritis,  diagnosticated  from  typhoid  fe- 
ver, 212 
Epididymitis,  in  typhoid  fever,  188 
Epistaxis,  in  typhoid  fever,  166,  169 
Eruption,  of  cerebro-spinal  fever,  77 
of  typhoid  fever,  167,  168 
of  typhus  fever,  169,  277 
Erysipelas,  after  relapsing  fever,  333 
facial,  in  typhoid  fever,  189 
in  cerebro-spinal  fever,  78 
in  typhus  fever,  2S0,  285 
Erythema,  in  cerebro-spinal  fever,  78 
Exanthem,  in  dengue,  353 
Exanthems,   diagnosticated  from  typhoid 

fever,  211 
Excreta,  decomposing,  in  etiology  of  ty- 
phoid fever,  124 
Eye,  condition  of,  in  cerebro-spinal  fever. 85 
disorders  of,  in  typhoid  fever,  167,  191 
disorders  of,  in  typhus  fever,  268 

Febricttla,  1 
Fever,  ardent  continued,  4 
Fever,  asthenic  simple,  4 
Fever,  cerebro-spinal,  46 

analysis  of  the  symptoms  of,  72 

clinical  history  of,  64 

complications  and  sequels  of,  87 

diagnosis  of,  94 


INDEX. 


361 


Fever,  cerebro-spinal,  disturbances  of  the 
organs  of  special  sense  in,  85 

etiology  of,  56 

historical  sketch  of,  47 

pathology   and    morbid    anatomy  of, 
89 

prognosis  and  mortality  of,  97 

symptoms  referable  to  the  organs  of 
respiration  in,  84 

symptoms  referable  to  the  skin  in,  77 

treatment  of,  98 

varieties,  69,  71 
Fever,  enteric  or  typhoid  (see  Fever,  ty- 
phoid), 107 
Fever,  herpetic,  6 
Fever,  infantile  remittent,  195 
Fever,     pernicious    intermittent,     distin- 
guished from  cerebro-spinal  fever,  95 
Fever,  relapsing,  302 

anatomical  lesions  of,  336 

analysis  of  the  principal  symptoms  of, 
324 

clinical  history  of,  320 

complications  and  sequels  of,  333 

diagnosis  of,  337 

diagnosticated  from  typhoid,  211 

etiology  of,  309 

exciting  cause  of,  312 

following  typhus,  319 

historical  sketch  of,  303 

prognosis  and  mortality  of,  335 

symptoms  due  to  disturbance  of  the 
digestive  organs  in,  331 

treatment  of,  340 
Fever,  remittent,  diagnosticated  from  re- 
lapsing fever,  339 

diagnosticated  from  typhoid,  211 

diagnosticated  from  typhus  fever.  296 
Fever,  scarlet,  distinguished  from  cerebro- 
spinal fever,  95 
Fever,  simple  continued,  1 

analysis  of  symptoms  of,  5 

diagnosticated  from  typhoid,  211 

clinical  history  of,  3 

duration  and  diagnosis  of,  7 

etiology  of,  3 

prognosis,   mortality,   and    treatment 
of,  8 
Fever,  typhoid,  107 

analysis  of  the  chief    symptoms   of, 
153 

anatomical  lesions  of,  202 


Fever,  typhoid,  clinical  history  of,  147 
complications  and  sequels  of,  178 
diagnosis  of,  210 
differential  diagnosis  of,  95,  338 
etiology  of,  116 
exciting  cause  of,  120 
expectant  treatment  of,  234 
geographical  distribution,  115 
historical  sketch  of,  108 
management   of   the   patient   during 

convalescence  from,  240 
prognosis  and  mortality  of,  213 
relapses  of,  196 

special  forms  of  treatment  of,  227 
symptoms  referable  to  the  circulatory 

system  in,  161 
symptoms  referable  to  the  digestive 

tract  in,  170 
symptoms   referable   to    the   nervous 

system  in,  163 
symptoms  referable  to  the  organs  of 

respiration  in,  176 
skin,  condition  of,  in,  1 67 
treatment  of  special  symptoms,  com- 
plications, and  sequels  of,  235 
treatment  and  prophylaxis  of,  221 
urine,  condition  of,  in,  177 
varieties  of,  193 
Fever,  typho-malarial,  196 
Fever,  typhus.  241 

analysis  of  the  principal  symptoms  of, 

264 
anatomical  lesions  of,  293 
clinical  history  of,  260 
complications  and  sequels  of,  284 
diagnosis  of,  295 
diagnosticated     from     cerebro-spinal 

fever,  96 
diagnosticated  fron!i  typhoid,  211 
differential  diagnosis  of,  338 
exciting  cause  of,  256 
etiology  of,  251 
following  relapsing  fever,  319 
fomites  of,  258 
historical  sketch  of,  242 
phenomena  of  the  fever  in,  269 
prognosis  and  mortality  of,  290 
symptoms  manifested  by  the  skin  in, 

277 
symptoms  referable  to  the  respiratory 

and  digestive  systems  in,  281 
treatment  of,  297 


362 


INDEX. 


Fever,  typhus,  varieties  of,  288 
Fomites,  in  typhoid  fever,  130 
in  typhus  fever,  258 

Gangrene,  in  relapsing  fever,  333 
of  the  lung  in  typhoid  fever,  182 
of  the  lung  in  typhus  fever,  285 
Germ,  of  enteric  fever,  121 
reproduction  of,  136 
capable  of  repioducing  itself  outside 

of  the  human  body,  143 
elimination  of,    with    the    fecal  dis- 
charges, 140 
must  undergo  certain  changes  before 
it  becomes  capable  of  producing  the 
disease,  141 
propagated  by  the  atmosphere,  145 
remains  in  vyater  and  is  conveyed  by 

it,  144 
retains   its   activity  for   a  long  time, 
U2 
Glossitis,  in  typhus  fever,  287 
Gurgling,  in  right  iliac   fossa  in   typhoid 
fever,  174 

Hair,  falling  of,  in  typhoid  fever,  189 
Hematuria,  in  typhoid  fever,  188 
Hasmoptysis,  in  typhus  fever,  285 
Hallucinations,  in  cerebro-spinal  fever,  73 
Headache,  in  cerebro-spinal  fever,  72 

in  influenza,  32 

in  relapsing  fever,  324 

in  typhoid  fever,  163,  235 

in  typhus  fever,  264,  300 
Hearing,  disturbances  of,  in  cerebro-spinal 

fever,  86 
Heart,    condition    of,    in     cerebro-spinal 
fever,  90 

changes  in,  in  relapsing  fever,  337 

changes  in  the  muscle  of,  in  typhoid 
fever,  208 

enfeeblement  of,  in  tjrphoid  fever,  162 
Hemorrhage,  from  the  bowels,  in  typhoid 

fever,  174,  238 
Hemorrhages,  cutaneous,  in  typhoid  fever, 
189 

in  relapsing  fever,  332 

in  typhus  fever,  285 
Herpes,  in  cerebro-spinal  fever,  77 

ia  influenza,  35 

in  typhoid  fever,  188 

in  typhus  fever,  280 


Hiccough,  in  typhoid  fever,  165 
Hydrocephalus,    chronic,    after    cerebro- 
spinal fever,  88 
Hypostasis,  in  typhoid  fever,  176 
Hyperaesthesia,  cutaneous,  in  typhoid  fe- 
ver, 107 
in  cerebro-spinal  fever,  76 
Hysteria,  97 

Infantile  remittent  fever,  195 
Infarctions,  hemorrhagic,  in  typhoid  fever, 

182 
Influenza,  10 

analysis  of  the  symptoms  of,  29 

clinical  history  of,  26 

complications  and  sequela  of,  33 

diagnosticated  from  typhoid  fever,  21 2 

etiology  of,  21 

historical  sketch  of,  12 

morbid  anatomy  and  diagnosis  of,  37 

pathology  of,  30 

prognosis  and  mortality  of,  38 

symptoms   referable  to    the   nervous 
system  in,  32 

treatment  of,  39 
Insomnia,  in  relapsing  fever,  325 
Intelligence,  feebleness   of,  after  cerebro- 
spinal fever,  87 
Intestines,  changes  in,  in  relapsing  fever, 
330 

changes  in,  in  typhoid  fever,  203 

perforation  of,  in  typhoid  fever,  185 
Iritis,  a  sequel,  of  relapsing  fever,  334 

Jaundice,  in  cerebro-spinal  fever,  84 

in  relapsing  fever,  321,  332 

in  typhoid  fever,  185 

in  typhus  fever,  287 
Joints,  affection  of.  in  dengue,  352 

inflammation  of,  in  cerebro-spinal  fe- 
ver, 85 

Kidneys,    condition  of,  in  cerebro-spinal 
fever,  91 

changes  in,  in  typhoid  fever,  208 
changes  in,  in  typhus  fever,  293 

Laryngitis,  acute,  in  influenza,  35 
in  typhoid  fever,  179 
in  typhus  fever,  284 
in  relapsing  fever,  333 


INDEX. 


363 


Liver,  abscess  of,  in  typhoid  fever,  185 
condition  of,  in  cerebro-spinal  fever,  91 
changes  in,  in  typhoid  fever,  207 
changes  in,  in  typhus  fever,  294 
changes  in,  in  relapsing  fever,  387 
enlargement  of,  in  relapsing  fever,  331 

Locality,  in  etiology  of  cerebro-spinal  fe- 
ver, 58 

Lungs,  changes  in,  in  relapsing  fever,  337 
changes  in,  in  cerebro-spinal  fever,  90 
gangrene  of,  in  typhus  fever,  285 
hypostatic  congestion  of,  in  typhoid 
fever,  181 

Lymphatics,  in  dengue,  353 

Mania,  in  typhoid  fever,  190 

Measles,  diagnosticated  from  typhus  fever, 

296 
Meat,  diseased,  in  etiology  of  typhoid  fe- 
ver, 133 
Membranes  of  the  spinal  cord,  condition 

of,  in  cerebro-spinal  fever,  92 
Memory,  weak,  after  cerebro-spinal  fever, 

87 
Meningitis,    diagnosticated   from   typhoid 
fever,  213 

epidemic,  96,  97 
in  typhoid  fever,  189 
tuberculous  basilar,  distinguished  from 
cerebro-spinal  fever,  94 
Menstruation,  in  typhoid  fever,  188 
Mesenteric  glands,  changes  in,  in  typhoid 

fever,  306 
Meteorism,  in  typhoid  fever,  173 
Mode  of  death,  in  cerebro-spinal  fever,  98 
Mucous  membrane,  gastro- intestinal  chan- 
ges in,  in  typhus  fever,  293 

intestinal,  in  cerebro-spinal  fever,  91 
Muscles,  changes  in  the  voluntary,  in  ty- 
phoid fever,  208 

condition  of,  in  cerebro-spinal  fever, 

90 
changes  in,  in  typhus  fever,  293 
disorders  of,  in  typhoid  fever,  165 

Nails,  condition  of,  in  typhoid  fever,  189 
Nausea,  in  relapsing  fever,  331 

in  typhoid  fever,  171 

in  typhus  fever,  283 
Neck,  stiffness  of,  in  cerebro-spinal  fever, 
74 


Necrosis,  in  typhus  fever,  387 
Nervous  system,    condition  of,  in  simple 
continued  fever,  G 

symptoms  pertaining  to,  in  cerebro- 
spinal fever,  72 
symptoms  referable  to,  in  influenza, 

33 
symptoms    referable    to,    in   typhoid 
fever,  163 
Neuralgia,  a  sequel  of  relapsing  fever,  334 
in  influenza,  35 
in  typhoid  fever,  191 
Noma,  in  typhus  fever,  287 
Nutrition,  state  of,  in  cerebro-spinal  fever, 
83 


CEdema,  pulmonary,  in  typhoid  fever,  181 , 

210 
Occupation,  in  etiology  of  typhoid  fever,  119 

in  etiology  of  typhus,  253 
Ophthalmia,  post- febrile,  334 
Opium,  in  cerebro-spinal  fever,  103 
Orchitis,  in  typhoid  fever,  188 
Otorrhcea,  in  typhoid  fever,  191 
Overcrowding,  in  the  etiology  of  typhus, 

353 

Pachymeningitis,  hemorrhagic,  a  sequel 

of  relapsing  fever,  334 
Pain,  in  influenza,  33 

in  relapsing  fever,  335 

in  typhoid  fever,  163 

abdominal,  in  typhoid  fever,  171 

in  typhus  fever,  264 
Pancreas,  changes  in,  in  typhoid  fever,  210 

changes  in,  in  typhus  fever,  294 
Paralysis,  in  cerebro-spinal  fever,  76 

after  cerebro-spinal  fever,  87 

in  typhoid  fever,  190 

in  typhus  fever,  2G7,  287 

local,  after  relapsing  fever,  334 
Parotid    gland,    swelling   of,    in    cerebro- 
spinal fever,  85 

inflammation  of,  in  influenza,  35 

inflammation  of,  in  typhus  fever,  286 

swelling  of,  after  relapsing  fever,  333 

swelling  of,  in  typhoid  fever,  184 
Perforation,  intestinal,  in  typhoid  fever, 

185 
Pericarditis  and  endocarditis  in  typhoid  fe- 
ver, 184 


364 


INDEX. 


Pericardium,     condition    of,    in   cerebro- 
spinal fever,  91 
Peritonitis,   diagnosticated    from  typhoid 
fever,  212 

in  typhoid  fever,  239 
in  typhus  fever,  294 
Petechia,  in  cerebrospinal  fever,  78 
in  typhoid  fever,  169 
"         in  typhus  fever,  2G1 
Phlegmasia  dolens,  in  typhus  fever,  285 
Phthisis,  in  typhus  fever,  285 
Physiognomy,  of  typhoid  fever,  170 
Pia  mater,  condition  of,  in  cerebro-spinal 
fever,  91 

in  typhoid  fever,  209 
Plague,  diagnosticated  from  typhus  fever, 

296 
Pleura,  condition  of,  in  cerebro-spinal  fe- 
ver, 91 
Pleurisy,  in  cerebro-spinal  fever,  87 
in  influenza,  35 
in  relapsing  fever,  333 
in  typhoid  fever,  183 
in  typhus  fever,  285 
Pleurosthotonos,  in   cerebro-spinal   fever, 

75 
Pneumonia,    catarrhal    and    croupous,  as 
complications  of  influenza,  33 
in  cerebro-spinal  fever,  87 
in  relapsing  fever,  333 
in  typhoid  fever,  182 
in  typhus  fever,  284 
Pregnancy,  in  influenza,  35 
with  relapsing  fever,  323 
with  typhoid  fever,  188 
with  typhus  fever,  288 
influencing  the  mortality  in  typhoid 
fever,  220 
Prophylaxis,  in  cerebro-spinal  fever,  98 

in  typhoid  fever,  221 
Protomycetes,  of  relapsing  fever,  312 
Pulse,  in  relapsing  fever,  328 
in  typhoid  fever,  IGl 
in  typhus  fever,  272 
Pupil,  condition  of,   in  cerebro-spinal  fe- 
ver, 85 
Pyemia,  in  typhus  fever,  285 

Rachialgia,  in  cerebro-spinal  fever,  76 
Relapses,  in  dengue,  355 
in  typhus  fever,  290 


Relapsing  fever  fsee  Fever),  302 
Remittent  fever,  diagnosticated  from  re- 
lapsing fever,  339 
Respiration,    symptoms    referable    to   the 
organs  of,  in  cerebro-spinal  fever,  84 
symptoms  referable  to  the  organs  of, 
in  typhoid  fever,  176 
Restlessness,  in  cerebro-spinal  fever,  74 
Retinitis,  a  sequel  of  relapsing  fever,  334 
Roseola,  in  cerebro-spinal  fever,  78 

Salivaky  glands,  changes  in,  in  typhoid 

fever,  209 
Scarlatina,  diagnosticated  from    cerebro- 
spinal fever,  95 
Season  of  the  year,  in  etiology  of  cerebro- 
spinal fever,  37 
in  etiology  of  relapsing  fever,  309 
in  etiology  of  typhoid  fever,  116 
in  etiology  of  tj-phus  fever,  251 
Secretions,  the,  in  influenza,  30 
Sewage,  in  etiology  of  typhoid  fever,  122 
Sex,  in  etiology  of  typhoid  fever,  119 
in  etiology  of  typhus  fever,  252 
influencing  mortality  in  typhoid  fever, 
220 
Simple  continued  fever  (see  Fever),  1 
Skin,  condition  of,  in  cerebro-spinal  fever, 
90 

condition  of,  in  simple  continued  fe- 
ver, 5 
hypersesthesia  of,  in  cerebro-spinal  fe^ 

ver,  76 
in  relapsing  fever,  330 
state  of,  in  typhoid  fever,  167 
symptoms    referable   to,   in   cerebro- 
spinal fever,  77 
Sleeplessness,  in  cerebro-spinal  fever,  74 
in  typhoid  fever,  235 
treatment  of.  in  typhus  fever,  300 
Small-pox,    diagnosticated  from    typhoid 

fever,  211 
Sordes,  in  typhoid  fever,  236 

in  typhus  fever,  282 
Somnolence,  in  typhoid  fever,  165,  235 
Spinal  cord,  changes  in,  in  cerebro-spinal 
fever,  93 

condition    of   the   membranes    of,    in 
cerebro-spinal  fever,  92 
Spine,  contraction  of  the  erector  muscles 

of,  in  cerebro-spinal  fever,  74 
Spirilli,  of  Obermeier,  322 


INDEX. 


365 


Spleen,  abscess  of,  in  relapsing  fever,  333 
condition  of,  in  cerebrospinal  fever, 

«4,  91 
changes  in,  in  relapsing  fever,  337 
condition  of,  in  typhoid  fever,  172,  207 
changes  in,  in  typhus  fever,  293 
enlargement   of,    in   relapsing   fever, 

333 
enlargement  of,  in  typhus  fever,  2S3 

Splenization,  in  typhoid  fever,  210 

Stomach,    changes  in,  in  relapsing  fever, 
336 

changes  in,  in  typhoid  fever,  203 

Sudamina,  in  cerebio-spinal  fever,  78 
in  typhoid  fever,  109 

Synocha,  1 

Temperature,  in  cerebro-spinal  fever,  78 

in  etiology  of  typhoid  fever,  117 

in  influenza,  29 

in  simple  continued  fever,  5 

in  relapsing  fever,  326 

in  typhoid  fever,  153 

in  typhus  fever,  269 
Tenderness,  abdominal,  in  typhoid  fever, 

171 
Thirst,  in  cerebro-spinal  fever,  84 

in  typhoid  fever,  171 

in  typhus  fever,  282 
Thrombosis,  venous,  in  typhoid  fever,  183 
Tinnitus  aurium,  in  influenza,  16 
Tongue,  condition  of,  in  cerebro-spinal  fe- 
ver, 84 

condition  of,  in  relapsing  fever,  331 

in  typhoid  fever,  17(),  236 

in  typhus  fever,  282 
Tremor,  in  typhoid  fever,  236 
Trichiniasis,  diagnosticated  from  typhoid 
fever,  213 


Trismus,  in  cerebro-spinal  fever,  75 
Tuberculosis,    acute,  diagnosticated  from 
typhoid  fever,  212 

acute  miliary,  after  typhoid  fever,  182 
Tympany,  in  typhoid  fever,  237 

in  typhus  fever,  283 
Typhoid  fever,  107 
Typho-malarial  fever,  196 
Typhus  fever,  241 

Urine,  condition  of,  in  cerebro-spinal  fe- 
ver, 85 

condition  of,  in  relapsing  fever,  321 

condition  of,  in  simple  continued  fe- 
ver, 5 

condition  of,  in  typhoid  fever,  177 

in  dengue,  353 

in  relapsing  fever,  330 

in  typhus  fever,  274,  280 

retention  of,  in  typhoid  fever,  165 
Urticaria,  in  cerebro-spinal  fever,  78 

in  dengue,  353 

Ventricles,   cardiac,   dilatation    of,   in 

typhoid  fever,  183 
Vertigo,  in  cerebro-spinal  fever,  73 

in  relapsing  fever,  324 

in  typhoid  fever,  163 

in  typhus  fever,  264 
Vibices,  in  typhus  fever,  279 
Vomiting,  in  cerebro-spinal  fever,  73 

in  relapsing  fever,  331 

in  typhoid  fever,  171 

in  typhus  fever,  282 

Wakefulness,  in  typhoid  fever,  165 
Weather,  state  of,  in  etiology  of  typhoid 
fever,  117 


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